Pandey et al.

BMC Health Services Research (2021) 21:741

https://doi.org/10.1186/s12913-021-06750-4

RESEARCH Open Access

Impacts of English language proficiency on

healthcare access, use, and outcomes
among immigrants: a qualitative study
Mamata Pandey1*, R. Geoffrey Maina2, Jonathan Amoyaw3, Yiyan Li2, Rejina Kamrul4, C. Rocha Michaels4 and
Razawa Maroof4

Abstract
Background: Immigrants from culturally, ethnically, and linguistically diverse countries face many challenges during
the resettlement phase, which influence their access to healthcare services and health outcomes. The “Healthy
Immigrant Effect” or the health advantage that immigrants arrive with is observed to deteriorate with increased
length of stay in the host country.
Methods: An exploratory qualitative design, following a community-based research approach, was employed. The
research team consisted of health researchers, clinicians, and community members. The objective was to explore
the barriers to healthcare access among immigrants with limited English language proficiency. Three focus groups
were carried out with 29 women and nine men attending English language classes at a settlement agency in a
mid-sized city. Additionally, 17 individual interviews were carried out with healthcare providers and administrative
staff caring for immigrants and refugees.
Results: A thematic analysis was carried out with transcribed focus groups and healthcare provider interview data.
Both the healthcare providers and immigrants indicated that limited language proficiency often delayed access to
available healthcare services and interfered with the development of a therapeutic relationship between the client
and the healthcare provider. Language barriers also impeded effective communication between healthcare
providers and clients, leading to suboptimal care and dissatisfaction with the care received. Language barriers
interfered with treatment adherence and the use of preventative and screening services, further delaying access to
timely care, causing poor chronic disease management, and ultimately resulting in poor health outcomes. Involving
untrained interpreters, family members, or others from the ethnic community was problematic due to
misinterpretation and confidentiality issues.
Conclusions: The study emphasises the need to provide language assistance during medical consultations to
address language barriers among immigrants. The development of guidelines for recruitment, training, and effective
engagement of language interpreters during medical consultation is recommended to ensure high quality,
equitable and client-centered care.
Keywords: Language barriers, Immigrants, Healthcare access, Healthcare utilisation, Health outcomes

* Correspondence: [email protected]
1
Research Department, Wascana Rehabilitation Centre, Saskatchewan Health
Authority, 2180-23rd Ave, Regina, SK S4S 0A5, Canada
Full list of author information is available at the end of the article

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Pandey et al. BMC Health Services Research (2021) 21:741 Page 2 of 13

Background Aery and colleagues [34] argue that the rights that
Major immigrant-destination countries like the United allow individuals access to language interpreters in the
States, Germany, Canada, and Australia admit a large justice system are also applicable in the healthcare con-
share of immigrants from culturally and linguistically di- text. Without language assistance, individuals with lan-
verse countries [1]. According to the 2016 Canadian guage barriers cannot engage in their treatment,
Census, foreign-born individuals make up more than determine risks and benefits of suggested treatment,
one-fifth (21.9%) of the Canadian population, which is and/or provide informed consent [34, 35]. Human rights
close to the highest level (22.3%), recorded in the 1921 legislations in Canada have provided a framework and
Census [2]. Most immigrants to Canada come from highlight the necessity to provide language interpreters
countries like the Philippines, India, China, Nigeria, and when needed, but these have not been implemented uni-
Pakistan, where most citizens’ first language is neither versally [35]. Some provinces in Canada have launched
English nor French [3–5]. Individuals without local lan- language interpretation services. These services include:
guage proficiency are more likely to have lower income, the Language Services Toronto in Ontario, language ser-
and face considerable challenges with economic and social vices for French-Canadians offered by Winnipeg Health
integration [6–8]. These settlement challenges increase Region in Manitoba and CanTalk telephonic interpreter
the risk of poor health outcomes among newcomers with services approved by the Saskatchewan Health Authority
limited language proficiency [9]. Newcomers also face in- in Saskatchewan [35–38]. Professional interpreter ser-
equities in healthcare settings [10]. Due to immigration re- vices are not covered under most provincial health pol-
quirements, most newcomers are healthier than the icies and therefore might not be available in all
general population, an effect referred to as the “healthy jurisdictions [3]. In the absence of universal interpret-
immigrant effect.” This effect is observed to decline over ation services across the country, healthcare providers
time [11–13]. Limited language proficiency is associated rely on professional interpreters, interpreters from
with decline in self-reported health status of new immi- community-based organizations and/or ad hoc (un-
grants during the first 4 years of stay in Canada [9]. trained) interpreters such as family members, friends,
The ability to speak the host country’s official language and volunteers who lack understanding of medical ter-
proficiently appears to be an essential determinant of minology and disease [3, 36–38]. Although the services
health [13–16]. The ability to speak, read, and write in the of professional language interpreters are employed in
local language is necessary to communicate with healthcare many Canadian healthcare settings, reliance on ad hoc
providers and interact in other social settings [17–19]. interpreters, is preponderant [35]. This is partly due to a
Language is consistently identified as a barrier for im- lack of trained interpreters in the language required and
migrants and refugees seeking, accessing, and using new immigrants’ lack of knowledge about available lan-
mental health services [11, 12, 15, 20]. Lee and col- guage supports [10]. Providers are also not comfortable
leagues [21] argued that Chinese immigrant women with interpreters as it is time consuming, and providers
are more likely to choose service providers who speak might have different expectations about the roles of in-
the same language. Marshall, Wong, Haggerty, and terpreters [3]. The impacts of local language proficiency
Levesque [4] observed that Chinese- and Punjabi- on immigrants’ health and well-being are relevant and
speaking individuals with limited English language have been studied in other major immigrant-destination
proficiency might delay accessing healthcare to find countries such as Australia, the United Kingdom, the
providers who speak their language. In the absence of United States of America [15, 17, 25, 32].
culture-specific words and due to stigma, individuals This topic is particularly relevant in the Canadian con-
from some ethnics groups may have difficulty describ- text as 72.5% of immigrants are reported to have a
ing mental health conditions or describe them as mother tongue other than English or French according
somatic symptoms [12, 22–24]. Lack of language sup- to the 2016 Census [39]. Given the unique history, cul-
port or culturally appropriate services can interfere ture, ethnic composition, and organization of healthcare
with timely mental health diagnosis and/or utilization services in Canada, scholars have highlighted the need
of mental health services [12, 23, 24]. for Canadian-based studies exploring how language bar-
Language-incongruent encounters within the healthcare riers contribute to inefficiencies within the Canadian
system increase the risk of inadequate communications, healthcare system and what strategies can be developed
misdiagnosis, medication errors and complications, and to address the gaps [10, 15]. This study explores the im-
even death [15, 19, 25]. Studies indicate that language pact of language barriers at each point of contact with
barriers adversely affect health outcomes, healthcare the healthcare delivery system, from the perspective of
access, utilization and cost of healthcare services, immigrants and healthcare providers in a Canadian
health-providers’ effectiveness, and patient satisfaction province that is witnessing a rapid influx of immigrants
and safety [15, 25–33]. [2]. Taking a comprehensive approach, the study
Pandey et al. BMC Health Services Research (2021) 21:741 Page 3 of 13

examined the overall impacts of language barriers on hereafter referred to as “clients.” Please refer to demo-
healthcare access, satisfaction with care received and graphic information of clients in Table 1.
health outcomes.
Data collection
The focus group discussion (FGD) questions were devel-
Methods
oped in consultation with the settlement agency staff
The study was set in a mid-size prairie city. An explora-
and focused on: a) the clients’ perceptions of health and
tory qualitative research approach guided by the princi-
the services needed to stay healthy; b) differences be-
ples of community-based research methods was
tween the healthcare systems in the client’s country of
adopted. Clinicians on the research team experienced
origin and Canada; c) access to healthcare services; d)
many challenges while caring for both immigrants and
challenges clients faced when accessing care in Canada;
refugees with language barriers. These clinicians
and, e) how clients made decisions about healthcare. Cli-
approached community members for their perspective.
ents received the questions before the FGD to organize
The study idea was conceived after collective brain-
their thoughts. Medical students representing specific
storming with multi-sectoral stakeholders, including:
ethnic groups and speaking an additional language
representatives from a non-government settlement
assisted with data collection and interpretation during
agency providing various settlement services to immi-
the FGDs.
grants, family physicians caring for both immigrants and
Three FGDs were held at the settlement agency and
refugees in the city, and health researchers. Each stake-
lasted 2 h with breaks for refreshments. Each FGD was
holder represented a specific ethnic-minority group and
attended by 10–15 clients and subgroups of 3–4 clients
arrived in Canada as a landed immigrant. Through per-
were coordinated by a facilitator speaking the same lan-
sonal experiences and professional interactions with
guage. Clients with language barriers were supported by
other immigrants, the stakeholders knew about barriers
facilitators speaking their language, other clients with
experienced during healthcare access.
advanced English language proficiency, or language
Thereafter, stakeholders developed a research partner-
interpreters.
ship. They collectively decided to document these chal-
Responses from clients were written down by facilita-
lenges and leverage the research results to advocate for
tors and reread to the clients for accuracy. Some clients
improved healthcare services. The study aim was to ex-
had written down their thoughts in English using online
plore the perspectives of immigrants and of healthcare
translators prior to the actual FGD to help them verbal-
providers. Other groups, such as temporary migrant
ise their thoughts with ease. Clients read out their re-
workers and refugees, have other unique challenges not
sponses during the FGDs and handed in those written
within the scope of the study. Community partners
notes after the FGDs. Facilitators also wrote field notes
assisted the research team to finalize the research ques-
of the salient points emerging from these sessions and
tion and determine methods of participant recruitment.
their reflections, which informed subsequent FGDs.
The study was carried out in two parts and approved by
None of the clients received services from any of the
the provincial health authority’s research ethics board
family physicians on the research team during data col-
(REB 14–122 and REB 15–69).
lection. Complementary child minding, light refresh-
ments and a $20 gift card to a grocery store were
Part 1 provided as incentives to participate.
Participants
A purposeful sampling method was used. Community Part 2
partners assisted with participant recruitment by en- Participants
gaging those seeking services through a settlement In part 2, healthcare providers’ perspectives on caring
agency. All participants recruited were immigrants. The for immigrants and refugees were explored to show a
consent form and roles of research participants were more comprehensive view of the situation. Seventeen
shared with all 43 individuals attending English language healthcare providers and health administrative staff
classes at the settlement agency. Language assistance signed the consent form: four family physicians, two
was provided by interpreters and the English language family physicians providing obstetrical care, a psych-
teachers facilitating the classes. Thirty-seven individuals iatrist, a registered nurse, a lab technician, a pharmacist,
(28 female and nine male) from 15 different countries a nutritionist, a psychiatric social worker, a counsellor,
signed consent forms. Three participants were travelling, an exercise therapist, an ultrasound technician, an ex-
two just began English language classes and one partici- ecutive director, and a receptionist. They were recruited
pant was not interested and were excluded. All partici- from a community clinic that predominantly served ref-
pants lived in Canada for less than 6 years and are ugees, immigrants, and other socio-economically
Pandey et al. BMC Health Services Research (2021) 21:741 Page 4 of 13

Table 1 Sociodemographic information and current health Table 1 Sociodemographic information and current health
information recorded from participants, by gender information recorded from participants, by gender (Continued)
Female Male Female Male
n (%) 28 9 Asia (Afganistan, China, India, Pakistian, Phillipines, 22
(75.7%) (24.3%) Russia, and South Korea)
What is your Age? (M,SD) 37.6 (7.9) 41.1 Europe (Hungary, Poland, Turkey and Ukraine) 10
(7.1)
Africa (Egypt, Tunisia, Eretria) 4
What is your Marital Status? n (%)
South America 1
Married or common law 25 8
(89.3%) (88.9%) Current Health Status

Divorced 1 (3.6%) 1 How is your health at present?

(11.1%) Good 18 6
(64.3%) (66.7%)
Missing 2 (7.1%) N/A
Alright 10 3
What level of Education you completed? n (%)
(35.7%) (33.3%)
Elementary Schooling (grade 10) 1 (3.6%) 1
(11.1%) Bad N/A N/A

High school 5 (17.9%) 5 Do you get tired easily?

(55.6%) Yes 6 (21.4%) 2
Trades and or vocation 1 (3.6%) 1 (22.2%)
(11.1%) No 4 (14.3%) 3
(33.3%)
Undergraduate 18 2
(64.3%) (22.2%) Sometimes 18 4
Missing 3 (10.7%) N/A (64.3%) (44.4%)

How many child you have? n (%) Do you have problems with your sleep?

0 5 (18%) N/A Yes 18 4

(64.3%) (44.4%)
1–3 20 (71%) 8
(88.9%) Sometimes 7 (25%) 3
(33.3%)
>3 2 (7.1%) 1
No 3 (10.7%) 2
(11.1%)
(22.2%)
missing 1 (3.6%) N/A
How many other individuals live with you in the same house? n
(%)
1–3 17 3
(60.7%) (33.3%)
4–6 10 3 disadvantaged populations in the city, other medical
(35.7%) (33.3%) clinics in the city, and a hospital.
>6 N/A 1
(11.1%) Data collection
Alone N/A 1 Healthcare providers serving immigrants and refugees
(11.1%) participated in an hour-long, in-depth individual inter-
Missing 1 (3.6%) 1 view focusing on a) health services required to better ad-
(11.1%) dress the healthcare needs of immigrants and refugees;
What is the total family income in a year? n (%) b) the availability of culturally-responsive healthcare ser-
0-$30,000 9 (32.1%) 1 vices; and c) the barriers to providing such care. Family
(11.1%) physicians on the research team with extensive experi-
$30,000–$50,000 6 (21.4%) 2 ence caring for immigrants and refugees assisted with
(22.2%) the development of the interview guide and data collec-
$50,000–$100,000 4 (14.3%) 3 tion. Interviews were carried out in English and were
(33.3%) audio recorded. No compensation was provided.
Missing 9 (32.1%) 3
(33.3%)
Analysis
How long have you stayed in Canada?: 2.8 (1.9) 3.4(.15) The FGDs and healthcare provider interviews were tran-
Mean (SD) years
scribed verbatim. Data was analyzed qualitatively using
Continent of origin n NVivo version 9 following the procedure proposed by
Pandey et al. BMC Health Services Research (2021) 21:741 Page 5 of 13

Miles, Huberman, and Saldana [40, 41]. During prelim- The range of healthcare services offered in different
inary data analysis, two rich transcripts were open coded countries differs significantly. Lack of knowledge about
by a team of researchers. Although the project was car- existing healthcare services in the city created a barrier,
ried out to explore barriers to healthcare access for im- which was greatly influenced by clients’ local language
migrants, language barriers emerged as a distinct theme proficiency. A healthcare provider in the study commen-
impacting various aspects of care during data analysis. ted that,
The results were shared with the settlement agency rep-
resentatives. A collective decision was made to highlight “We need to make the community or the clients’
the impacts of limited English language proficiency on population know that this is available for you and
healthcare access, utilization, and outcomes for immi- this is the process how you get access to this service,
grants in this manuscript. This framework guided the the language barrier is a huge barrier for this popu-
rest of the data analysis. The research team collectively lation and to access like any health care service.”
reviewed the completed data analysis report and no new
themes emerged at this discussion. The research team The way in which healthcare is organized and coordi-
collectively agreed that further clarifications were not re- nated varies from country to country, and for new-
quired from participants. Therefore, follow-up focus comers, understanding the services provided within the
groups or interviews were not carried out and no new host country largely depends on their ability to decipher
participants were recruited.. information about them. Those with language limita-
Data was broken into 120 base-level codes. The base- tions might not know how to access various healthcare
level codes were reviewed a second time, and codes with services. This can lead to misunderstanding between the
similar concepts were consolidated into 45 intermediate client and the provider, causing frustrations and unful-
codes. The intermediate codes were categorized under filled expectations for both, as one healthcare provider
11 sub-themes. Title was assigned to each sub-theme to noted:
highlight the diverse and pertinent concepts represented
by each sub-theme. The sub-themes were then orga- “I offer free prescription delivery, but clients didn't
nized under four central themes. Diagrammatic repre- come to the door, they didn't understand that the
sentation shows the relationship between the 11 sub- delivery person is delivering it and all they're doing
themes and the four themes and is illustrated in Fig. 1. is going to the door, ringing the doorbell expecting
Field notes maintained by facilitators were used to cross- them to be let in. On numerous occasions, we were
reference the themes emerging during data analysis to unsuccessful because they [clients] wouldn't open the
ensure all pertinent themes were included. The diagram door, there was no one there or-they did not under-
demonstrating the relationship with the subthemes was stand, so, unless someone on the other end speaks
approved by all team members. English and tells us they're going to be there, we
won't deliver now.”
Results
Impacts of limited English language proficiency have Experience with healthcare delivery in clients’ countries
been summarized under four main themes as follows. of origin and cultural beliefs about health and what
healthcare services should be accessed can interfere with
Theme 1: ability to access health information and services their healthcare access. Language barriers may impede a
Language proficiency significantly impacted a client’s client’s ability to understand the differences between
ability to identify services needed, to secure appoint- healthcare organization in Canada and in their country
ments, and to effectively engage with healthcare pro- of origin, leading to the underutilization of healthcare
viders while seeking care and managing post- services, as one healthcare provider explained:
appointment care and follow-up. Information about
healthcare services is usually provided in English or “If you don't know their language, it becomes difficult
French. Thus, a client with language barriers lacked ad- to provide care to them. Also, cultural beliefs can
equate information about available services and was un- interfere with access to care. For example, they [im-
able to access services promptly. Clients with language migrants and refugees with language barrier] do not
barriers are less likely to actively seek health and/or know how to access an optometrist or dentist. So, I
mental health services when needed, as is evident from a have to give them a lot of information as they have
client’s comment: “No do not know about mental health no idea.”
services because of the language problem. Can I go to the
hospital to access it?” [client]. Another client inquired: Due to language barriers, clients experienced difficulty
“Do I need appointments for blood tests?” following conversations with receptionists, providing
Pandey et al. BMC Health Services Research (2021) 21:741 Page 6 of 13

Fig. 1 Language Proficiency Leads to Poor Healthcare Access, Suboptimal Care, and Dissatisfaction with Care

proper documentation required for coordinating care, Clients reported experiencing difficulty asking questions
and booking and attending appointments. Clients with about their health and understanding treatment instruc-
language barriers were less likely to seek clarifications tions. One client mentioned that,
when they did not understand instructions or to advo-
cate for their needs. As one client noted, “I don’t speak “Sometimes, the doctors describe the illness in a way
good English. Therefore, sometimes it is difficult to under- that I don’t understand what the doctors say. Some-
stand what the receptionist is saying.” times this makes it very hard to go to the doctors be-
Similarly, a health administrative staff mentioned “I cause of the language problems.”
am still waiting for the healthcare number from three cli-
ents. They [clients with language barrier] do not under- Healthcare providers were often concerned about not
stand it is necessary for billing purposes”. getting adequate information about health concerns
The degree to which clients with limited language pro- from patients with language barriers. They experienced
ficiency are able to access the healthcare services they difficulties during physical examinations or when provid-
need largely depends on their ability to understand in- ing treatment instructions, which can have adverse out-
formation that is written in English and to understand comes, as one healthcare provider explained:
how the healthcare system is organized.
“Say I am treating an ear infection. I have told the
Theme 2: ability to develop a therapeutic alliance with clients many times that the medication is to be ad-
healthcare providers ministered by mouth, but they thought it was to be
English language proficiency significantly affected the installed in the ears. So, I have a couple of disastrous
therapeutic relationship between patients and healthcare cases where I have prescribed medication where they
providers. Clients with language barriers were unable to don’t realize it is given by mouth. I think also, when
explain their health conditions adequately, as one client they don’t understand, they feel uncomfortable to
noted: ask for clarification. They get very embarrassed and
they get very frustrated.”
“Without proficiency in English, it is difficult talking
to the health care provider. It's a problem to describe Similarly, clients with English language barriers also
what you're feeling. It will be easier as a newcomer if mentioned difficulty understanding medication regime
they have a family doctor who speaks the same lan- as a client mentioned.
guage. Like for children with pain, it is difficult for
them to say what they [children] want or to make “I had problems with the iron levels, the doctors pre-
them [children] understand.” scribed iron pills. I asked the doctors how many to
Pandey et al. BMC Health Services Research (2021) 21:741 Page 7 of 13

take, but he did not explain it properly. He first said Some clients were also concerned that their messages
that I should take one pill a day, then when I ask if were not communicated properly to the healthcare pro-
that will be enough, he said I can take 2 to 3 pills. viders during translation as a client mentioned:
How can he advise me like that without explaining
it properly?” “I cannot speak English so I cannot go by myself to
the doctor … … Before I had to wait for my husband
Theme 3: challenges with engaging language interpreters he works, and say everything fast as he had to go
Language interpreters are not available at all clinics and back to work soon, I could not say everything I
families often bring ad hoc interpreters to the appoint- wanted, to the doctors, but now my son comes with
ments or use volunteers working within the healthcare me so it is better but I have to remind him always to
system. Often, these ad hoc interpreters lack adequate say everything I said, to the doctor as he is still
skills and training to carry out medical translation, young and may forget.”
which creates additional challenges. Healthcare pro-
viders may not feel confident that instructions are being A medical interpreter’s presence can create privacy and
translated verbatim. They also noted that often they re- confidentiality issues, especially for clients with mental
ceived a summarized or concise version of what the cli- health issues. Interpreters assisting clients with mental
ents narrated and wondered whether valuable contextual illness require training to create culturally safe interac-
information was lost during translation. This can be tions, lest the interaction become more injurious to the
frustrating for the healthcare providers and interfere clients than the illness itself. The excerpt below from a
with the development of the therapeutic alliance, as a healthcare provider is an excellent example of culturally
healthcare provider pointed out: unsafe medical translation.

“Some of the barriers I've experienced, those mainly “I had this case where the interpreter was not
had to do with communication and interpreters. I trained in mental health, and they found the conver-
guess sometimes I wonder with the translation, what sation to be funny, so it was an elderly Asian lady
is being said to the patient. because they have quite who had delusions and hallucinations—well, we had
a long discussion, and then when I ask the inter- a hard time with that. The interpreter was
preter what was said … oh, they have no questions. laughing.”
*laughs* so I'm not sure what the conversation was,
so that can be a little bit, um, frustrating.” Some clients were uncomfortable receiving language as-
sistance from family or individuals of the same commu-
Further, some interpreters might provide a cultural and/ nity. As is mentioned by a women client:
or religious interpretation of strategies that might not
align with Western medical care, as this healthcare pro- “I need lady doctor or lady speaking my language. I
vider explained: need medicine to stop baby [contraception] where
can I get it. I cannot talk about this with my doctors
“There are times when the clients will bring in their when others [family members who help with transla-
interpreters that I don't feel that my teaching and tion] are there with me and I am waiting for 3
my advice is being given to them appropriately or months now.”
word for word. I find that the personal interpreters
they bring in will contraindicate and conflict with Moreover, healthcare providers were sometimes con-
what I am telling the client because they will say "no cerned about the quality of the translation services pro-
that's not how we do things" instead of telling the cli- vided to their clients. Healthcare providers observed that
ent what I as a practitioner would like them to do”. some interpreters struggled to explain instructions ad-
equately during sample collection and diagnostics tests,
Sometimes, ad hoc interpreters are less helpful in assist- leading to delays in the treatment process and linkage to
ing with client-provider communication and they may treatment. One healthcare provider conveyed the issues
become an impediment to the therapeutic alliance, as a with inadequate medical translation:
healthcare provider noted:
“I requested that the client present with a stool sam-
“Sometimes working with an interpreter is difficult ple in the container provided. A couple of times,
because you don't always know whether the transla- some clients showed up with urine in there rather
tor translates exactly what you're trying to come than stool. This is after numerous explanations with
across or explain.” an interpreter present.”
Pandey et al. BMC Health Services Research (2021) 21:741 Page 8 of 13

Another healthcare provider mentioned that: from healthcare setting, as was explained by this health-
care provider:
“Giving simple instructions such as the need for a
full bladder before ultrasound, many don’t under- “First of all, they [clients] might not understand
stand what bladder is. Last week I tried to conduct what I'm telling them when I'm asking them to ad-
spirometry on a patient even with the presence of an minister insulin themselves and increasing their
interpreter and I was not successful. He just didn't doses based on their numbers. A lot of times they’re
understand. I guess he [interpreter] did not translate very confused on that fact and the translation, some-
accurately.” thing is getting lost in the translation. Any misunder-
standing can put them in a very dangerous situation
Effective communication between healthcare providers if they give themselves too much insulin.”
and clients is vital for providing safe and quality
healthcare. Language ability can interfere with chronic disease man-
agement, which requires continual monitoring through
Theme 4: impacts of language barriers on health regular clinic appointments. Even with medical transla-
outcome and strategies addressing gaps tion, some clients may not comprehend the steps in the
Clients with language barriers often manage care on treatment plan that they are required to follow to man-
their own and due to lack of effective communication age chronic conditions effectively. Without additional
they are often dissatisfied with care received. Clients felt supports available after medical appointments, these pa-
as though it was not worth seeking care when there was tients struggle to set up follow-up appointments, refill
no means of addressing their language limitations, as prescriptions, and adhere to medical instructions. In the
one client noted: absence of supports, treatment adherence might be poor.
A healthcare provider describes what happens when cli-
“This country has so much resources and sometimes ents don’t receive post-appointment follow-up or
I feel the resources are not put to good use. What is support:
the point of seeing a doctor if I do not feel satisfied?
First, you must make appointments, manage every- “A lot of them [clients] have chronic conditions such
thing at home to go for that appointment, and then as hypertension and don't come for a routine check-
still wait when you reach there, and then the doctors up. You'll see them and start them on medication and
hardly spend time with you.” try to emphasize that this is long term treatment, and
they will need to come back in a month for a check-
In many countries healthcare is accessed on a need to up. You'll see that they've shown up a year later, and
basis and individuals might not have understanding yet they were prescribed medications to last them for
about preventative health. Emphasis is given on pre- one month only and didn't renew them even though
ventative medicine in Canada, but providing health edu- they had renewals. They will show up a year later
cation can be challenging due to language barriers as a with a headache or something, and their blood pres-
healthcare provider pointed out: sure is way out of control. I see that a lot.”

“If they don’t understand the preventative or the Clients mentioned adopting few strategies to address
treatment plan but instead of perhaps doing some language barriers. Women clients often preferred same
preventative stuff, they want to jump right to the gender interpreters for women health issues and they
surgery or jump right to the medication. Like PAP depended on family and friend circles for assistance as a
smears and mammograms, there is a lack of educa- client mentioned: “I have a very good friend who took
tion in those countries where they come from. There holiday from work to come with me, I had to talk to the
are no concepts of preventative health care there. We doctor about women problem.” Clients also consulted
tried to offer an information session with interpreters friends or family to find relevant healthcare services near
it really slowed down the meeting; everyone had to them. A client mentioned: “I will ask my sister for
wait for the interpreter to interpret our directions healthcare for my family she and her family help us
and if we didn’t immediately have them interpret when we need information. I can also find out using the
the participants were having a hard time following internet.” Clients might also seek information about
the conversation” healthcare services and ways to access it from commu-
nity organizations providing settlement services as a cli-
Healthcare providers were apprehensive about the dan- ent mentioned: “I ask my English teacher when I need
gers that clients with language barriers might face away information about healthcare services they can help me.”
Pandey et al. BMC Health Services Research (2021) 21:741 Page 9 of 13

Some clients pointed out that finding providers from “I cannot speak English well and so cannot explain
their ethnic background would be helpful. Many clients what I need I got so frustrated with the doctors did
take it upon themselves to seek care from these pro- not go to see one in one whole year but that came to
viders and may delay healthcare access, as this partici- harm me. I now have pain in my ankle which is
pant mentioned: “I am waiting to find a doctor who growing but what is the use of telling the doctors I
speak my language and can understand my culture.” cannot explain properly and they will not under-
Matching clients with providers from the same linguistic stand and it will not help.”
and ethnic background is useful but challenging. It may
be more feasible in larger cities with larger and estab- Individuals might delay access to healthcare which in-
lished ethnic groups. A client who received care from a creases patients’ vulnerability to adverse health
provider from the same ethnic background mentioned a outcomes.
positive experience, as is evident from this comment:
Discussion
“My doctor is from my country and he was able to This study includes the perspectives of immigrants in a
explain to me why I need the surgery (hysterectomy). Canadian city and healthcare providers serving them.
I was scared and I did not want to do it, but my Consistent with the literature, both patients and pro-
husband and my doctor helped me understand that viders unanimously agreed that limited English language
it was needed and if I did not get it done I will get proficiency significantly impacts access to care, quality
very sick, I did it and I am alright now.” of care received, and health outcomes for immigrants
throughout the continuum of care [3, 10, 15–17, 26–29,
Alternatively, healthcare providers who are culturally 31, 33]. This study examined the impacts of language
attuned to the challenges that clients with language bar- barriers at all points of contact with the healthcare deliv-
riers face are often empathetic and accommodative and ery system. The study highlights that the impacts of lan-
ensure that clients receive the required care. One health- guage barriers are evident long before an individual
care provider noted: meets with a healthcare provider and persist long after
an individual has received a treatment or intervention.
“They experience barriers accessing health care due The cumulative impact of this is delayed access to timely
to language limitations. Some clients may have chal- healthcare, suboptimal care, increased risk of adverse
lenges with conceptualizing what constitutes good events, dissatisfaction with care received and poor health
health. This is partly informed by the fact that most outcomes. The study emphasizes that healthcare delivery
of them may have experienced marginalization for in Canada cannot be improved by providing language in-
so long. Therefore, [clients] might not have the right terpreters during medical consultation alone. A more
access to information or ask the right question. I try comprehensive approach is required that includes, devel-
to talk to them at their level of understanding.” oping best practice guidelines for providers, training for
interpreters and policy change to address the impacts of
Specialized clinics providing services to immigrants and language barriers on healthcare delivery, utilization and
refugees might have trained interpreters; however, their health outcomes in Canada. This study highlights four
time might be limited, and they might not be available ways in which limited English language proficiency can
for healthcare services outside the clinics. One health- interfere with immigrants’ healthcare access and health
care provider mentioned: outcomes.
As observed by Floyd and Sakellariou [29], clients in
“We are lucky to have interpreters in our clinic but our study were unaware of the available healthcare ser-
their time is limited and most of their time is allo- vices, lacked knowledge about ways to navigate the
cated for in-person appointments in the clinics and healthcare system, and were unable to advocate for
they might not be available to provide support for needed services [25]. Language barriers impacted clients’
other program such as health promotion.” engagement with prevention, health promotion, and al-
lied health services, which can create the misperception
To achieve a positive treatment outcomes among immi- that they are disengaged in care. Other studies have also
grants with language barriers, effective coordination of identified that language barriers influence access to and
care, good patient-provider communication and assist- use of preventative medicine and screening [30, 42–44].
ance with follow-up into the community post appoint- Language barriers interfere with the ability to find infor-
ment are required. Lack of these ancillary services mation about healthcare services and eligibility. This
discourages individuals from accessing healthcare ser- leads to fragmented, suboptimal care and/or delayed
vices. This is evident from a client’s comments: linkage with appropriate care [4, 30].
Pandey et al. BMC Health Services Research (2021) 21:741 Page 10 of 13

Clients and providers consistently mentioned that lan- that interpreters might not be able to translate treatment
guage barriers interfered with the development of thera- plans, instructions for sample collection, or instructions
peutic relationships. As observed in other studies, for screenings because of their lack of medical know-
language barriers impeded effective health information ledge. As discussed in the literature, the healthcare pro-
sharing and communication between patients and pro- viders in this study also highlighted issues with privacy
viders, thereby undermining trust [16, 26–30]. Similar to and confidentiality when ad hoc interpreters, family
what De Moissac and Bowen [38] observed, the clients members, or individuals from the same ethnic groups
in this study also mentioned difficulty describing pain are involved [3, 43, 50, 52]. Studies indicate that clients
and other symptoms to their healthcare providers, which with limited English language proficiency prefer profes-
can interfere with accurate diagnoses [25, 32, 45]. Clients sional gender-concordant interpreters over family mem-
with limited language abilities are at risk of delaying bers [53]. Although studies show that without medical
treatment [4, 38], misdiagnosis, or mismanagement of interpreters the quality of care is compromised for cli-
their conditions [38, 46]. Like those reported in other ents with language barriers, interpretation errors often
studies, our results also demonstrated specific instances occur when ad hoc interpreters are used [10, 16, 25, 26,
where language barriers increased the chances of med- 50, 52, 54]. Professional interpreters raise the quality of
ical errors and harms due to patient’s inability to under- clinical care compared to ad hoc interpreters [50, 54].
stand and/or follow treatment plans [15, 17, 25, 38]. Finally, the present study highlighted how English lan-
Consistent with the findings of systematic reviews [16, guage proficiency creates an additional layer of barriers
47], the providers in this study indicated that inter- to healthcare access, utilization, and patient satisfaction
preters were helpful. As observed in other studies [16, [3]. Inability to communicate effectively with healthcare
29, 30], clients in this study also emphasized the need providers creates dissatisfaction for patients because
for bilingual healthcare providers. Community health their needs were not communicated and they are not
navigators can help improve access to primary and pre- getting the services needed [16, 27]. Moreover, language
ventative healthcare services while acting as cultural bro- barriers limit a healthcare provider’s ability to provide
kers and language interpreters [48]. Molina and Kasper care in a timely, safe manner; subsequently, the client’s
called for language-concordant care, as it has been needs are unmet [4, 16, 17, 27, 32].
shown to provide safe and high-quality care [49]. Language barriers also create dissatisfaction for health-
However, this study adds to the discussion in the litera- care providers as they are unable to engage patients in
ture about the challenges that arise when ad hoc inter- health promotion and preventative programs [42, 44],
preters are involved [50]. Consistent with the literature, offer additional supports like home delivery for medica-
the healthcare providers in this study indicated that inter- tions, or support them with treatment adherence. Lan-
preters’ roles are often unstructured. Instead of verbatim guage barriers might cause embarrassment, disempower
translating, an interpreter might summarize information patients, and undermine patients’ confidence [25, 28,
or provide their own interpretation of what the patient 30]. Floyd & Sakellariou [29] observed that refugee
and/or the provider said, leading to suboptimal conversa- women with language barriers are likely to experience
tion and care [3, 42]. Interpreters are also unsure about racism, and might not be engaged in healthcare decision
their role in medical translation [18]. Although healthcare making. Additionally, cultural belief and experience with
providers wanted verbatim translation in our study, other the healthcare delivery system in the country of origin
studies observed that healthcare providers might expect influence the type of healthcare services that will be
interpreters to also act as cultural brokers or care coordi- accessed and expectation from healthcare providers [3,
nators [3, 18, 42]. Our results provided evidence of situa- 28, 30]. Due to a lack of culturally appropriate care, ac-
tions when some medical interpreters could not provide cess to healthcare services can be delayed or underuti-
culturally safe translation support, especially when sensi- lized [12, 24, 30, 31].
tive and taboo topics were involved [3]. Providers might Floyd and Sakellariou [29] observed that the Canadian
not feel comfortable or prepared to care for immigrants healthcare system is organized on the assumption that
with language barriers [25]. Language barriers may slow service seekers can read and understand English, which
down conversations and additional follow-ups are re- marginalizes immigrants, refugees, and others with lower
quired thereby increasing stress and workload for pro- literacy and limited English language proficiency.
viders [27, 42, 47, 51]. Parsons, Baker, Smith-Gorvie, and Hudak [55] men-
In this study, clients and providers both indicated that tion that it is unclear who is responsible for ensuring
multiple sessions might be required to communicate in- that communication between providers and patient is
structions for treatment and sample collection [42]. As adequate. Guidelines are required for healthcare pro-
observed by Ali and Watson [17] in the United King- viders outlining when interpreters should be involved.
dom, the healthcare providers in this study also reported Papic et al. [47] highlighted the need for clear directives
Pandey et al. BMC Health Services Research (2021) 21:741 Page 11 of 13

for determining who is responsible for arranging inter- Through professional courses, continued education,
preters and finding ways to enhance the involvement of and development of best practice guidelines health-
professional interpreters and multicultural clinics where care providers in Canada should be equipped with ad-
available. equate knowledge and skills to care for patients with
As a country that promotes and celebrates multicultur- language barriers [49].
alism, the Canadian Charter of Rights and Freedoms Interpreters in Canada should have clear instructions
(1982) guarantees equal rights, such that Canadians are to about whether only verbatim translation is required or
be treated with the same respect, dignity, and consider- they need to serve as cultural brokers and/or support cli-
ation regardless of race, nationality, ethnicity, color, reli- ents with coordination of care. A national strategy
gion, sex, or age [56]. Healthcare access needs to be should be developed in Canada to train, support, and
regarded as a basic human right under the Charter and supervise interpreters adequately to ensure that they de-
not be contingent on language proficiency. Although most liver safe, and impactful services [35].
immigrants arrive with better health status than the local
Acknowledgements
population, largely attributed to initial health selectivity We greatly appreciate the support received from the Executive Director of
and the Canadian immigration policy, their health status Regina Immigrant Women Center Mrs. Neelu Sachdev and her staff
tends to decline over time to levels worse than native- members during the project. We would especially like to thank the teachers
facilitating the English language classes, for helping with participant
born citizens [3, 57–60]. This deterioration has been recruitment, data collection, translation and data interpretation. We
partly attributed to discrimination and unfair treatment acknowledge the contributions of Cheghaf Madrati, Sarah Green Wood,
that immigrants experience in the healthcare system [60]. Tooba Zahid, Fatima Ahmed and Tannys Bozdech undergraduate medical
students who provided language support and assisted with writing the
Aery [61] proposed that a health equity perspective is response during the focus group discussion. We also want to thank
required to address the socio-cultural barriers faced by psychiatry resident Samra Sahlu for assistance with the healthcare provider
vulnerable populations, including immigrants and refu- interviews. Saskatchewan Health Authority and Department of Academic
Family Medicine (Regina Campus) University of Saskatchewan provided
gees. Ali and Waston [17] proposed that addressing lan- in-kind support for the project.
guage barriers is an essential step towards providing
culturally responsive and client-centered care. The im- Authors’ contributions
Mamata Pandey: She developed the research plan, carried out stake holder
portance of enabling patients to actively participate in consultation, prepared ethics application, collected data, analyzed data,
their healthcare has received extensive policy attention prepared the first draft of the manuscript. Geoffrey Maina: Assisted with
[62]. Giving patients an active role in their healthcare finalizing methodology, data analysis, writing methodology, data analysis,
results and implication section of the manuscript, extensively review and
empowers them and improves services and health out- revised the manuscript. Jonathan Amoyaw: Assisted with literature review,
comes [63]. Involving patients in shared decision making prepared the discussion, limitation and conclusion, reviewed and edited the
is emphasised in Saskatchewan, Canada [64]. Against manuscript. Yiyan Li: Assisted with introduction, literature review, figures and
tables and final editing of manuscripts. Rejina Kamrul: Helped with ethics
this backdrop, patients, providers, and interpreters in application, carried out consultation with community partners, development
Canada need to be engaged to understand the multi- of focus group and health care provider interview guides, data collection
layer barriers at the individual, community, and health- and analysis and reviewed the final draft of the manuscripts. Clara Rocha
Michaels: Assisted with consultation with stakeholders, reviewed ethics
system levels and address those needs [42]. application, development of healthcare provider interview guides, data
collection, data analysis and reviewed the final draft of the manuscripts.
Limitation of the study Razawa Maroof: Assisted with ethics application for part 2 of the study,
assisted in the development of the interview questions for healthcare
A small number of clients from each ethnic group was providers, carried out interviews with healthcare providers, reviewed the data
recruited; therefore, results might not reflect the experi- analysis and final draft of the manuscript. The author(s) read and approved
ence of the respective ethnic groups as a whole. With a the final manuscript.
larger number of female clients recruited in the study, Funding
the views are more reflective of female than male pa- This project did not receive any financial support.
tients with language barriers. A small number of health-
Availability of data and materials
care providers were recruited from each discipline. All data generated or analysed during this study are available from the
Further research is required to capture discipline- corresponding author on reasonable request.
specific challenges encountered by providers caring for
Declarations
patients with language barriers. The study did not in-
clude migrant workers and refugees and additional re- Ethics approval and consent to participate
search is required to highlight specific challenges This study was approved by the Research Ethics Board at Saskatchewan
Health Authority, Regina, Saskatchewan, Canada (REB 14–122 and REB 15–
experienced by specific groups. 69). All protocols were carried out in accordance with relevant guidelines
and regulations. All participants provided informed consent before
Implications for practice participating in the research activity.
The results of the study are relevant for any country Consent for publication
accepting immigrants from linguistically diverse countries. Not applicable.
Pandey et al. BMC Health Services Research (2021) 21:741 Page 12 of 13

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