Cultural Barriers Make It Harder for Immigrants to Access Healthcare

New report recommends ways to overcome language differences, other hurdles

Mariam Merced, director of the community health promotions program at Robert Wood Johnson University Hospital, which aims to have more trained medical interpreters on its staff.
Healthcare is harder to come by for immigrants living in New Jersey, often due to language barriers which make it difficult to establish relationships with primary care providers.

The state already requires healthcare professionals to learn to handle cultural and language differences as part of their training, but a new report recommends increased efforts to enroll more bilingual students in the state’s healthcare-related schools.


The recently released report by the Rutgers Centers for State Health Policy found a large gap between immigrants who aren’t citizens (including both undocumented or illegal immgrants and those who have a legal status but aren’t citizens) and other residents (including both immigrants who’ve become citizens and those born in the United States) in how frequently they visit healthcare providers and whether they have communication problems when they do.

The issue is particularly important for New Jersey, which ranks third in the country after California and New York in the share of its population who are immigrants. According to the 2010 census, 1.84 million New Jersey residents were immigrants, representing 21 percent of the population.

“Communications with providers and an ability to connect with your primary care provider is really important for optimal healthcare, particularly when it comes to complex chronic illnesses,” said Joel Cantor, the center’s director and an NJ Spotlight columnist.

Under the Affordable Care Act, immigrants with legal status must wait five years before they’re eligible for coverage under expanded Medicaid coverage, but they are eligible for subsidies to buy coverage through the federal health insurance marketplace. Undocumented or illegal immigrants aren’t eligible for coverage under the ACA but frequently receive treatment through federally qualified health centers.

While only 8 percent of New Jersey residents born in the United States had not seen a doctor or advanced practice nurse in the previous two years, 29 percent of noncitizen immigrants hadn’t.

And of those who had seen a provider, 41 percent of noncitizen immigrants had encountered a communication problem, compared with 31 percent of foreign-born citizens and 30 percent of U.S.-born residents. Those statistics are based on the 2009 New Jersey Family Health Survey, which was conducted by the center and supported by the Robert Wood Johnson Foundation.

These problems are particularly true for residents who have trouble understanding the language or accent of a provider, with immigrants having nearly three times as much language difficulty as native-born residents.

Cantor said that if communication problems occur during a conversation about something like high blood pressure, the consequences could be severe.

“They have not connected as well with healthcare providers as their citizen counterparts,” Cantor said of noncitizens.

He added that communications problems aren’t the only reason why immigrants have had shorter relationships with primary care providers – another reason is that some haven’t been in the country long enough to build these relationships.

One way that doctor’s offices and hospitals address the language barrier is by arranging for medical interpreters to be available by phone to translate between the patient and provider. But Cantor described this as a “second-best” solution.

“It’s really much better to have a trained medical interpreters in the room,” where they are better able to clear up any confusion, Cantor said.

New Jersey has been ahead of other states in requiring training for healthcare professionals in “culture competence,” which includes discussions of how to reach out and learn to communicate with patients from different ethnic or language backgrounds.

But the report also calls for an increased effort to enroll immigrants and other students who are fluent in languages other than English in medical and nursing programs.

Some healthcare systems are making progress in increasing the number of bilingual staff members.

In New Brunswick, Robert Wood Johnson University Hospital’s community health promotions program has been working to increase the number of trained medical interpreters in the hospital. Program Director Mariam Merced said the report confirmed challenges that she has observed first-hand.

“We have a large immigrant community with a small safety net that can address that,” said Merced, who added that communication problems frequently lead people to delay scheduling appointments.

Along with having relatively short-term relationships with providers, immigrants frequently lack health insurance and have problems with childcare and transportation, Merced said.

“Many work long hours,” Merced noted, adding that visiting a doctor “is a big to-do for them. If they don’t show up for work, they don’t get paid. All of this becomes a lot of barriers.”

Merced added that immigrants frequently have housing issues that complicate healthcare providers’ efforts to communicate and schedule appointments. Some immigrants move frequently, living with three or four families in homes that were built for one family.

“Many of them also have fear — because of their undocumented status — of providing information,” thereby risking deportation, Merced said.

Merced’s program provides 40 hours of communications training for staff. While most translations needed in New Brunswick are in Spanish, the program has also trained interpreters in Russian and Polish. Those who complete the program are tested to ensure that they’re fully bilingual. In addition, the hospital provides signs and forms in languages including Hindi, Gujarati and Mandarin Chinese.

Merced added that many immigrants come from regions or neighborhoods where access to healthcare is “very little or nonexistent,” so providers also must work to increase patients’ basic health literacy.

Robert Wood Johnson University Hospital also is working to plant the seeds for future bilingual healthcare providers. It has a partnership with the Health Sciences and Technology High School to train New Brunswick students for healthcare careers.