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• Published: 08 July 2021

Ten tips for overcoming language barriers in science

• Tatsuya Amano   ORCID: orcid.org/0000-0001-6576-3410 1 , 2 ,
• Clarissa Rios Rojas   ORCID: orcid.org/0000-0001-6544-4663 3 ,
• Yap Boum II 4 ,
• Margarita Calvo   ORCID: orcid.org/0000-0003-3349-9189 5 , 6 &
• Biswapriya B. Misra 7  

Nature Human Behaviour volume  5 ,  pages 1119–1122 ( 2021 ) Cite this article

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Language barriers have serious consequences in science, causing inequality for under-represented communities, making non-English-language knowledge inaccessible, and impeding the uptake of science by decision-makers. Here we provide a practical checklist as a starting point for tackling this overlooked issue.

Language barriers are a multifaceted problem that has major consequences in science. Just as one would in many other situations, any scientist or user of science can face difficulties in conducting and communicating science when it involves a language other than their mother tongue. It has often been perceived as the ‘English’ barrier encountered specifically by non-native speakers of English due to their own lack of linguistic capabilities. It certainly does, often quite severely, affect educational and career opportunities for non-native English speakers 1 , 2 , who constitute 95% of the global population. We often leave the task of overcoming the language (i.e., English) barrier almost entirely to the non-native English-speaking scientific community and ultimately to individuals trying to overcome the barrier through their own efforts and investments. However, tackling language barriers is clearly an urgent task for the entire scientific community if we are to address the existing inequality in academia.

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Ramírez-Castañeda, V. Disadvantages in preparing and publishing scientific papers caused by the dominance of the English language in science: the case of Colombian researchers in biological sciences. PLoS ONE 15 , e0238372 (2020).

Article   Google Scholar  

Clavero, M. “Awkward wording. Rephrase”: linguistic injustice in ecological journals. Trends Ecol. Evol. 25 , 552–553 (2010).

Amano, T., González-Varo, J. P. & Sutherland, W. J. Languages are still a major barrier to global science. PLoS Biology 14 , e2000933 (2016).

Saha, S., Afrad, M. M. H., Saha, S. & Saha, S. K. Towards making global health research truly global. Lancet Glob. Health 7 , e1175 (2019).

Amano, T., Rios Rojas, C., Boum II, Y., Calvo, M. & Misra B. B. Resources and opportunities for non-native-English speakers to overcome language barriers in science. OSF https://osf.io/wqmjn/ (2021).

Konno, K. et al. Ignoring non-English-language studies may bias ecological meta-analyses. Ecol. Evol. 10 , 6373–6384 (2020).

Estévez-Bretón, C. Raising the global visibility of non-English, non-STEM research: a case study from Colombia. Institutional Priorities White Paper (Elsevier, 2018).

Politzer-Ahles, S., Girolamo, T. & Ghali, S. Preliminary evidence of linguistic bias in academic reviewing. J. Engl. Acad. Purposes 47 , 100895 (2020).

Alshebli, B. K., Rahwan, T. & Woon, W. L. The preeminence of ethnic diversity in scientific collaboration. Nat. Commun. 9 , 5163 (2018).

Lynch, A. J. et al. Culturally diverse expert teams have yet to bring comprehensive linguistic diversity to intergovernmental ecosystem assessments. One Earth 4 , 269–278 (2021).

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Acknowledgements

We thank the eLife Ambassador program for bringing the authors together to discuss this important topic. Thanks also to W. J. Sutherland for his invaluable feedback on an earlier draft and M. Amano for all the support. T.A. is supported by the Australian Research Council Future Fellowship (FT180100354) and the University of Queensland strategic funding.

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School of Biological Sciences, The University of Queensland, Brisbane, Queensland, Australia

Tatsuya Amano

Centre for Biodiversity and Conservation Science, The University of Queensland, Brisbane, Queensland, Australia

Centre for the Study of Existential Risk, University of Cambridge, Cambridge, UK

Clarissa Rios Rojas

Epicentre, Yaoundé, Cameroon

Yap Boum II

Physiology Department, Pontificia Universidad Católica de Chile, Santiago, Chile

Margarita Calvo

Millennium Nucleus for the Study of Pain (MiNuSPain), Santiago, Chile

Independent Researcher, Namburu, India

Biswapriya B. Misra

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Correspondence to Tatsuya Amano .

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B.B.M. currently works as a Principal Scientist with Enveda Biosciences but did not receive any funding for this work.

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Peer review information Nature Human Behaviour thanks Emilio Bruna, Caroline Wagner and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Amano, T., Rios Rojas, C., Boum II, Y. et al. Ten tips for overcoming language barriers in science. Nat Hum Behav 5 , 1119–1122 (2021). https://doi.org/10.1038/s41562-021-01137-1

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Changes in research on language barriers in health care since 2003: A cross-sectional review study

Affiliations.

• 1 Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA. Electronic address: [email protected].
• 2 White Memorial Medical Center, Los Angeles, CA, USA.
• 3 School of Leadership Studies, Royal Roads University, Victoria, BC, Canada.
• 4 Alvarado-Little Consulting, Albany, NY, USA.
• 5 Rutgers University School of Nursing, Newark, NJ, USA.
• 6 Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco General Hospital, San Francisco, CA, USA.
• 7 Department of Psychiatry & Behavioral Sciences & Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Department of Healthcare Policy and Research, Weil Cornell Medical College, New York, NY, USA.
• 8 Department of Psychiatry & Behavioral Sciences & Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
• 9 Asian Americans Advancing Justice-Los Angeles, Los Angeles, CA, USA.
• 10 Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA; Deparment of Population Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
• PMID: 25816944
• PMCID: PMC4943579
• DOI: 10.1016/j.ijnurstu.2015.03.001

Background: Understanding how to mitigate language barriers is becoming increasingly important for health care providers around the world. Language barriers adversely affect patients in their access to health services; comprehension and adherence; quality of care; and patient and provider satisfaction. In 2003, the United States (US) government made a major change in national policy guidance that significantly affected limited English proficient patients' ability to access language services.

Objective: The objectives of this paper are to describe the state of the language barriers literature inside and outside the US since 2003 and to compare the research that was conducted before and after a national policy change occurred in the US. We hypothesize that language barrier research would increase inside and outside the US but that the increase in research would be larger inside the US in response to this national policy change.

Methods: We reviewed the research literature on language barriers in health care and conducted a cross sectional analysis by tabulating frequencies for geographic location, language group, methodology, research focus and specialty and compared the literature before and after 2003.

Results: Our sample included 136 studies prior to 2003 and 426 studies from 2003 to 2010. In the 2003-2010 time period there was a new interest in studying the providers' perspective instead of or in addition to the patients' perspective. The methods remained similar between periods with greater than 60% of studies being descriptive and 12% being interventions.

Conclusions: There was an increase in research on language barriers inside and outside the US and we believe this was larger due to the change in the national policy. We suggest that researchers worldwide should move away from simply documenting the existence of language barriers and should begin to focus their research on documenting how language concordant care influences patient outcomes, providing evidence for interventions that mitigate language barriers, and evaluating the cost effectiveness of providing language concordant care to patients with language barriers. We think this is possible if funding agencies around the world begin to request proposals for these types of research studies. Together, we can begin document meaningful ways to provide high quality health care to patients with language barriers.

Keywords: Cross sectional review; Language barriers; Limited English proficiency; Policy change.

Copyright © 2015 Elsevier Ltd. All rights reserved.

Publication types

• Research Support, N.I.H., Extramural
• Research Support, Non-U.S. Gov't
• Communication Barriers*
• Cross-Sectional Studies
• Health Services Research / trends*

Grants and funding

• UL1 TR000427/TR/NCATS NIH HHS/United States
• P30 CA008748/CA/NCI NIH HHS/United States
• UL1 RR025011/RR/NCRR NIH HHS/United States
• 1UL1RR025011/RR/NCRR NIH HHS/United States
• 9U54TR000021/TR/NCATS NIH HHS/United States

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Language and communication in international students’ adaptation: a bibliometric and content analysis review

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• Michał Wilczewski   ORCID: orcid.org/0000-0001-7650-5759 1 &
• Ilan Alon   ORCID: orcid.org/0000-0002-6927-593X 2 , 3  

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This article systematically reviews the literature (313 articles) on language and communication in international students’ cross-cultural adaptation in institutions of higher education for 1994–2021. We used bibliometric analysis to identify the most impactful journals and articles, and the intellectual structure of the field. We used content analysis to synthesize the results within each research stream and suggest future research directions. We established two major research streams: second-language proficiency and interactions in the host country. We found inconclusive results about the role of communication with co-nationals in students’ adaptation, which contradicts the major adaptation theories. New contextualized research and the use of other theories could help explain the contradictory results and develop the existing theories. Our review suggests the need to theoretically refine the interrelationships between the interactional variables and different adaptation domains. Moreover, to create a better fit between the empirical data and the adaptation models, research should test the mediating effects of second-language proficiency and the willingness to communicate with locals. Finally, research should focus on students in non-Anglophone countries and explore the effects of remote communication in online learning on students’ adaptation. We document the intellectual structure of the research on the role of language and communication in international students’ adaptation and suggest a future research agenda.

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Introduction

One of the consequences of globalization is the changing landscape of international higher education. Over the past two decades, there has been a major increase in the number of international students, that is, those who have crossed borders for the purpose of study (OECD, 2021a ), from 1.9 million in 1997 to over 6.1 million in 2019 (UIS Statistics, 2021 ). Even students who are motivated to develop intercultural competence by studying abroad (Jackson, 2015 ) face several challenges that prevent them from benefitting fully from that experience. Examples of these challenges include language and communication difficulties, cultural and educational obstacles affecting their adaptation, socialization, and learning experiences (Andrade, 2006 ), psychological distress (Smith & Khawaja, 2011 ), or social isolation and immigration and visa extension issues caused by Covid-19 travel restrictions (Hope, 2020 ).

Cross-cultural adaptation theories and empirical research (for reviews, see Andrade, 2006 ; Smith & Khawaja, 2011 ) confirm the critical importance of foreign-language and communication skills and transitioning to the host culture for a successful academic and social life. Improving our understanding of the role of foreign-language proficiency and communication in students’ adaptation is important as the number of international students in higher education worldwide is on the rise. This increase has been accompanied by a growing number of publications on this topic over the last decade (see Fig.  1 ). Previous reviews of the literature have identified foreign-language proficiency and communication as predictors of students’ adaptation and well-being in various countries (Smith & Khawaja, 2011 ). The most recent reviews (Jing et al., 2020 ) list second-language acquisition and cross-cultural adaptation as among the most commonly studied topics in international student research. However, to date, there are no studies specifically examining the role of language and communication in international students’ adaptation (henceforth “language and communication in student adaptation”). This gap is especially important given recent research promoting students’ self-formation (Marginson, 2014 ) and reciprocity between international and domestic students (Volet & Jones, 2012 ). The results challenge the traditional “adjustment to the host culture” paradigm whereby international students are treated as being out of sync with the host country’s norms (Marginson, 2014 ). Thus, this article differs from prior research by offering a systematic and in-depth review of the literature on language and communication in student adaptation using bibliometric co-citation analysis and qualitative content analysis. Our research has a methodological advantage in using various bibliometric tools, which should improve the validity of the results.

Source: HistCite). Note . TLC, total local citations received; TGC, total global citations received; Articles, number of articles published in the field; International Students, number (in millions) of international students worldwide (UIS Statistics, 2021 )

Yearly publication of articles on language and communication in student adaptation (

We focus on several questions:

What are the most impactful journals and articles about the role of language and communication in student adaptation?

What is the thematic structure of the research in the field?

What are the leading research streams investigating language and communication in student adaptation?

What are the effects of language and communication on student adaptation?

What are the future research directions?

After introducing the major concepts related to language and communication in student adaptation and the theoretical underpinnings of the field, we present our methodology. Using bibliometric and content analysis, we track the development of the field and identify the major themes, research streams, and studies that have shaped the state-of-the art and our current knowledge about the role of language and communication in student adaptation. Finally, we suggest avenues for future research.

Defining the concepts and theories related to language and communication in student adaptation

Concepts related to language and communication.

Culture is a socially constructed reality in which language and social practices interact to construct meanings (Burr, 2006 ). In this social constructionist perspective, language is viewed as a form of social action. Intertwined with culture, it allows individuals to communicate their knowledge about the world, as well as the assumptions, opinions, and viewpoints they share with other people (Kramsch, 1998 ). In this sense, people identify themselves and others through the use of language, which allows them to communicate their social and cultural identity (Kramsch, 1998 ).

Intercultural communication refers to the process of constructing shared meaning among individuals with diverse cultural backgrounds (Piller, 2007 ). Based on the research traditions in the language and communication in student adaptation research, we view foreign or second-language proficiency , that is, the skill allowing an individual to manage communication interactions in a second language successfully (Gallagher, 2013 ), as complementary to communication (Benzie, 2010 ).

Cross-cultural adaptation

The term adaptation is used in the literature interchangeably with acculturation , adjustment , assimilation , or integration . Understood as a state, cultural adaptation refers to the degree to which people fit into a new cultural environment (Gudykunst and Hammer, 1988 ), which is reflected in their psychological and emotional response to that environment (Black, 1990 ). In processual terms, adaptation is the process of responding to the new environment and developing the ability to function in it (Kim, 2001 ).

The literature on language and communication in student adaptation distinguishes between psychological, sociocultural, and academic adaptation. Psychological adaptation refers to people’s psychological well-being, reflected in their satisfaction with relationships with host nationals and their functioning in the new environment. Sociocultural adaptation is the individual’s ability to fit into the interactive aspects of the new cultural environment (Searle and Ward, 1990 ). Finally, academic adaptation refers to the ability to function in the new academic environment (Anderson, 1994 ). We will discuss the results of the research on language and communication in student adaptation with reference to these adaptation domains.

Theoretical underpinnings of language and communication in student adaptation

We will outline the major theories used in the research on international students and other sojourners, which has recognized foreign-language skills and interactions in the host country as critical for an individual’s adaptation and successful international experience.

The sojourner adjustment framework (Church, 1982 ) states that host-language proficiency allows one to establish and maintain interactions with host nationals, which contributes to one’s adaptation to the host country. In turn, social connectedness with host nationals protects one from psychological distress and facilitates cultural learning.

The cultural learning approach to acculturation (Ward et al., 2001 ) states that learning culture-specific skills allows people to handle sociocultural problems. The theory identifies foreign-language proficiency (including nonverbal communication), communication competence, and awareness of cultural differences as prerequisites for successful intercultural interactions and sociocultural adaptation (Ward et al., 2001 ). According to this approach, greater intercultural contact results in fewer sociocultural difficulties (Ward and Kennedy, 1993 ).

Acculturation theory (Berry, 1997 , 2005 ; Ward et al., 2001 ) identifies four acculturation practices when interacting with host nationals: assimilation (seeking interactions with hosts and not maintaining one’s cultural identity), integration (maintaining one’s home culture and seeking interactions with hosts), separation (maintaining one’s home culture and avoiding interactions with hosts), and marginalization (showing little interest in both maintaining one’s culture and interactions with others) (Berry, 1997 ). Acculturation theory postulates that host-language skills help establish supportive social and interpersonal relationships with host nationals and, thus, improve intercultural communication and sociocultural adjustment (Ward and Kennedy, 1993 ).

The anxiety/uncertainty management (AUM) theory (Gudykunst, 2005 ; Gudykunst and Hammer, 1988 ) states that intercultural adjustment is a function of one’s ability to cope with anxiety and uncertainty caused by interactions with hosts and situational processes. People’s ability to communicate effectively depends on their cognitive resources (e.g., cultural knowledge), which helps them respond to environmental demands and ease their anxiety.

The integrative theory of communication and cross-cultural adaptation (Kim, 2001 ) posits that people’s cultural adaptation is reflected in their functional fitness, meaning, the degree to which they have internalized the host culture’s meanings and communication symbols, their psychological well-being, and the development of a cultural identity (Kim, 2001 ). Communication with host nationals improves cultural adaptation by providing opportunities to learn about the host country’s society and culture, and developing intercultural communication competence that includes the ability to receive and interpret comprehensible messages in the host environment.

The intergroup contact theory (Allport, 1954 ; Pettigrew, 2008 ) states that contact between two distinct groups reduces mutual prejudice under certain conditions: when groups have common goals and equal status in the social interaction, exhibit intergroup cooperation, and have opportunities to become friends. Intercultural contact reduces prejudice toward and stereotypical views of the cultural other and provides opportunities for cultural learning (Allport, 1954 ).

These theories provide the theoretical framework guiding the discussion of the results synthesized through the content analysis of the most impactful articles in the field.

Methodology

Bibliometric and content analysis methods.

We used a mixed-method approach to review the research on language and communication in student adaptation for all of 1994–2021. This timeframe was informed by the data extraction process described in the next section. Specifically, we conducted quantitative bibliometric analyses such as co-citation analysis, keyword co-occurrence analysis, and conceptual thematic mapping, as well as qualitative content analysis to explore the research questions (Bretas & Alon, 2021 ).

Bibliometric methods use bibliographic data to identify the structures of scientific fields (Zupic and Čater, 2015 ). Using these methods, we can create an objective view of the literature by making the search and review process transparent and reproducible (Bretas and Alon, 2021 ). First, we measured the impact of the journals and articles by retrieving data from HistCite concerning the number of articles per journal and citations per article. We analyzed the number of total local citations (TLC) per year, that is, the number of times an article has been cited by other articles in the same literature (313 articles in our sample). We then analyzed the total global citations (TGC) each article received in the entire Web of Science (WoS) database. We also identified the trending articles in HistCite by calculating the total citation score (TLCe) at the end of the year covered in the study (mid-2021). This score rewards articles that received more citations within the last three years (i.e., up to the beginning of 2018). Using this technique, we can determine the emerging topics in the field because it considers not only articles with the highest number of citations received over a fixed period of time, but also those that have been cited most frequently in recent times (Alon et al., 2018 ).

Second, to establish a general conceptual structure of the field, we analyzed the co-occurrence of authors’ keywords using VOS software. Next, based on the authors’ keywords, we plotted a conceptual map using Biblioshiny (a tool for scientific mapping analysis that is part of the R bibliometrix-package) to identify motor, basic, niche, and emerging/declining themes in the field (Bretas and Alon, 2021 ).

Third, to determine specific research streams and map patterns within the field (Alon et al., 2018 ), we used the co-citation mapping techniques in HistCite that analyze and visualize citation linkages between articles (Garfield et al., 2006 ) over time.

Next, we used content analysis to synthesize the results from the 31 most impactful articles in the field. We analyzed the results within each research stream and discussed them in light of the major adaptation theories to suggest future research directions and trends within each research stream (Alon et al., 2018 ). Content analysis allows the researcher to identify the relatively objective characteristics of messages (Neuendorf, 2002 ). Thus, this technique enabled us to verify and refine the results produced by the bibliometric analysis, with the goal of improving their validity.

Data extraction

We extracted the bibliographic data from Clarivate Analytics’ WoS database that includes over 21,000 high-quality, peer-reviewed scholarly journals (as of July 2020 from clarivate.libguides.com). We adopted a two-stage data extraction approach (Alon et al., 2018 ; Bretas and Alon, 2021 ). Table 1 describes the data search and extraction processes.

First, in June 2021, we used keywords that would best cover the researched topic by searching for the following combinations of terms: (a) “international student*” OR “foreign student*” OR “overseas student*” OR “study* abroad” OR “international education”—to cover international students as a specific sojourner group; (b) “language*” and “communicat*”—to cover research on foreign-language proficiency as well as communication issues; and (c) “adapt*” OR “adjust*” OR “integrat*” OR “acculturat*”—to cover the adaptation aspects of the international students’ experience. However, given that cross-cultural adaptation is reflected in an individual’s functional fitness, psychological well-being, and development of a cultural identity (Kim, 2001 ), we included two additional terms in the search: “identit*” OR “satisf*”—to cover the literature on the students’ identity issues and satisfaction in the host country. Finally, based on a frequency analysis of our data extracted in step 2, we added “cultur* shock” in step 3 to cover important studies on culture shock as one of critical aspects of cross-cultural adaptation (Gudykunst, 2005 ; Pettigrew, 2008 ; Ward et al., 2001 ). After refining the search by limiting the data to articles published in English, the extraction process yielded 921 sources in WoS.

In the second stage, we refined the extraction further through a detailed examination of all 921 sources. We carefully read the articles’ abstracts to identify those suitable for further analysis. If the abstracts did not contain one or more of the three major aspects specified in the keyword search (i.e., international student, language and communication, adaptation), we studied the whole article to either include or exclude it. We did not identify any duplicates, but we removed book chapters and reviews of prior literature that were not filtered out by the search in WoS. Moreover, we excluded articles that (a) reported on students’ experiences outside of higher education contexts; (b) dealt with teaching portfolios, authors’ reflective inquiries, or anecdotal studies lacking a method section; (c) focused on the students’ experience outside the host country or on the experience of other stakeholders (e.g., students’ spouses, expatriate academics); (d) used the terms “adaptation,” “integration,” or “identity” in a sense different from cultural adaptation (e.g., adaptation of a syllabus/method/language instruction; integration of research/teaching methods/technology; “professional” but not “cultural” identity); or (e) used language/communication as a dependent rather than an independent variable. This process yielded 313 articles relevant to the topic. From them, we extracted the article’s title, author(s) names and affiliations, journal name, number, volume, page range, date of publication, abstract, and cited references for bibliometric analysis.

In a bibliometric analysis, the article is the unit of analysis. The goal of the analysis is to demonstrate interconnections among articles and research areas by measuring how many times the article is (co)cited by other articles (Bretas & Alon, 2021 ).

• Bibliometric analysis

Most relevant journals and articles

We addressed research question 1 regarding the most impactful journals and articles about the role of language and communication in student adaptation by identifying the most relevant journals and articles. Figure  2 lists the top 20 journals publishing in the field. The five most influential journals in terms of the number of local and global citations are as follows: International Journal of Intercultural Relations (79 and 695 citations, respectively), Journal of Studies in International Education (28 and 343 citations, respectively), Journal of Multilingual and Multicultural Development (14 and 105 citations, respectively), Journal of Cross-Cultural Psychology (13 and 302 citations, respectively), and Higher Education (11 and 114 citations, respectively),

Source: HistCite). Note . TLC, total local citations received; TLC/t, total local citations received per year; TGC, total global citations received; Articles, number of articles published in the field

Top 20 journals publishing on language and communication in student adaptation (

Table 2  lists the 20 most influential and trending articles as measured by, respectively, local citations (TLC) and trending local citations at the end of the period covered (TLCe), that is, mid-2021. The most locally cited article was a qualitative study of Asian students’ experiences in New Zealand by Campbell and Li ( 2008 ) (TLC = 12). That study, which linked host-language proficiency with student satisfaction and effective communication in academic contexts, also received the highest number of global citations per year (TGC/t = 7.86). The most influential article in terms of total local citations per year was a quantitative study by Akhtar and Kröner-Herwig ( 2015 ) (TLC/t = 1.00) who linked students’ host-language proficiency, prior international experience, and age with acculturative stress among students in Germany. Finally, Sam’s ( 2001 ) quantitative study, which found no relationship between host-language and English proficiency and having a local friend on students’ satisfaction with life in Norway, received the most global citations (TGC = 115).

The most trending article (TLCe = 7) was a quantitative study by Duru and Poyrazli ( 2011 ) who considered the role of social connectedness, perceived discrimination, and communication with locals and co-nationals in the sociocultural adaptation of Turkish students in the USA. The second article with the most trending local citations (TLCe = 5) was a qualitative study by Sawir et al. ( 2012 ) who focused on host-language proficiency as a barrier to sociocultural adaptation and communication in the experience of students in Anglophone countries.

Keyword co-occurrence analysis

We addressed research question 2 regarding the thematic structure of the research in the field by analyzing the authors’ keyword co-occurrences to establish the thematic structure of the field (Bretas and Alon, 2021 ; Donthu et al., 2020 ). Figure  3 depicts the network of keywords that occurred together in at least five articles between 1994 and 2021. The nodes represent keywords, the edges represent linkages among the keywords, and the proximity of the nodes and the thickness of the edges represent how frequently the keywords co-occurred (Donthu et al., 2020 ). The analysis yielded two even clusters with 17 keywords each. Cluster 1 represents the primary focus on the role of language proficiency in student adaptation. It includes keywords such as “language proficiency,” “adaptation,” “acculturative stress,” “culture shock,” and “challenges.” Cluster 2 represents the focus on the role of intercultural communication and competence in student adaptation. It includes keywords such as “intercultural communication,” “intercultural competence,” “academic/psychological/sociocultural adaptation,” and “transition.”

Source: VOS)

Authors’ keyword co-occurrence analysis (

Conceptual thematic map

Based on the authors’ keywords, we plotted a conceptual map (see Fig.  4 ) using two dimensions. The first is density , which indicates the degree of development of the themes as measured by the internal associations among the keywords. The second is centrality , which indicates the relevance of the themes as measured by the external associations among the keywords. The map shows four quadrants: (a) motor themes (high density and centrality), (b) basic themes (low density and high centrality), (c) niche themes (high density and low centrality), and (d) emerging/declining themes (low density and centrality) (Bretas & Alon, 2021 ). The analysis revealed that motor themes in the field are studies of Chinese students’ experiences and student integration. Unsurprisingly, the basic themes encompass most topics related to language in student adaptation. Research examining the perspective of the students’ parents with regard to their children’s overseas experience exemplifies a niche theme. Finally, “international medical students” and “learning environment” unfold as emerging/declining themes. To determine if the theme is emerging or declining, we analyzed bibliometric data on articles relating to medical students’ adaptation and students’ learning environment. We found that out of 19 articles on medical students published in 13 journals (10 medicine/public health-related), 15 (79%) articles were published over the last five years (2016–2021), which clearly suggests an emerging trend. The analysis of authors’ keywords yielded only three occurrences of the keyword “learning environment” in articles published in 2012, 2016, and 2020, which may suggest an emerging trend. To further validate this result, we searched for this keyword in titles and abstracts and identified eight relevant articles published between 2016 and 2020, which supports the emerging trend.

Source: Biblioshiny)

Conceptual thematic map (

Citation mapping: research streams

We addressed research question 3 regarding the leading research streams investigating language and communication in student adaptation by using co-citation mapping techniques to reveal how the articles in our dataset are co-cited over time. To produce meaningful results that would not trade depth for breadth in our large dataset (313 articles), we limited the search to articles with TGC ≥ 10 and TLC ≥ 3. These thresholds yielded the 31 articles (10% of the dataset) that are most frequently cited within and outside the dataset, indicating their driving force in the field. We analyzed these 31 articles further because their number corresponds with the suggested range of the most-cited core articles for mapping in HistCite (Garfield et al., 2006 ).

Figure  5 presents the citation mapping of these 31 articles. The vertical axis shows how the articles have been co-cited over time. Each node represents an article, the number in the box represents the location of the article in the entire dataset, and the size of the box indicates the article’s impact in terms of TLCs. The arrows indicate the citing direction between two articles. A closer distance between two nodes/articles indicates their similarity. Ten isolated articles in Fig.  5 have not been co-cited by other articles in the subsample of 31 articles.

Source: HistCite)

Citation mapping of articles on language and communication in student adaptation (

A content analysis of these 31 articles points to two major and quite even streams in the field: (a) “ second-language proficiency ” (16 articles) and (b) “ interactions in the host country ” involving second-language proficiency, communication competence, intercultural communication, and other factors (15 articles). We clustered the articles based on similar conceptualizations of language and communication and their role in student adaptation. As Fig.  5 illustrates, the articles formed distinct but interrelated clusters. The vertical axis indicates that while studies focusing solely on second-language proficiency and host-country interactions have developed relatively concurrently throughout the entire timespan, a particular interest in host-country interactions occurred in the second decade of research within the field (between 2009 and 2013). The ensuing sections present the results of the content analysis of the studies in each research stream, discussing the results in light of the major theories outlined before.

Content analysis

We sought to answer research question 4 regarding the effects of language and communication on student adaptation by synthesizing the literature within the previously established two research streams. The concept map in Fig.  6 illustrates the predictive effects of second-language proficiency and host-country interactions on various adaptation domains. Table 4 in the Appendix presents a detailed description of the synthesis and lists studies reporting these effects, underscoring inconclusive results.

A concept map synthesizing research on language and communication in student adaptation

Second-language proficiency

This research stream focuses on language barriers and the role of foreign-language proficiency in student adaptation. Having host-language proficiency predicts less acculturative stress (Akhtar and Kröner-Herwig, 2015 ), while limited host-language proficiency inhibits communication with locals and academic integration (Cao et al., 2016 ). These results are in line with the acculturation theory (Berry, 1997 , 2005 ; Ward et al., 2001 ) and the communication and cross-cultural adaptation theory (Kim, 2001 ). Cross ( 1995 ) suggested that social skills predict sociocultural rather than psychological (perceived stress, well-being) adaptation (Searle and Ward, 1990 ). Indeed, several qualitative studies have explained that the language barrier affects sociocultural adaptation by preventing students from establishing contacts with host nationals (Wang and Hannes, 2014 ), developing meaningful relationships (Sawir et al., 2012 ), and limiting occasions for cultural learning (Trentman, 2013 ), supporting the acculturation theory (Anderson, 1994 ; Church, 1982 ; Searle and Ward, 1990 ).

Moreover, insufficient host-language proficiency reduces students’ satisfaction by hampering their communication, socialization, and understanding of lectures in academic contexts (Campbell and Li, 2008 ). Similarly, language affects academic adaptation in students who have difficulty communicating with domestic students (Young and Schartner, 2014 ) or when used as a tool in power struggles, limiting students’ opportunities to speak up in class and participate in discussions or decision-making (Shi, 2011 ). Students who have limited host-language proficiency tend to interact with other international students, which exacerbates their separation from domestic students (Sawir et al., 2012 ). These findings again confirm the theories of acculturation (Berry, 1997 ; Ward et al., 2001 ) and communication and cross-cultural adaptation (Kim, 2001 ).

With regard to the acculturation theory (Berry, 1997 ; Ward and Kennedy, 1999 ), we found inconclusive results concerning the impact of foreign-language skills on students’ satisfaction and adaptation. Specifically, some studies (e.g., Sam, 2001 ; Ying and Liese, 1994 ) found this effect to be non-significant when tested in regression models. One explanation for this result might be the indirect effect of language on adaptation. For instance, Yang et al. ( 2006 ) established that host-language proficiency mediated the relationship between contact with host nationals and the psychological and sociocultural adjustment of students in Canada. Swami et al. ( 2010 ) reported that better host-language skills among Asian students in Britain predicted their adaptation partly because they had more contacts with host nationals. In turn, Meng et al. ( 2018 ) found that the relationship between foreign-language proficiency and social and academic adaptation was fully mediated by global competence (understood as “intercultural competence” or “global mindset”) in Chinese students in Belgium.

Interactions in the host country

The second research stream comprises studies taking a broader look at language and communication in student adaptation by considering both individual and social interaction contexts: second-language (host-language and English) proficiency; willingness to communicate in the second language; communication interactions with domestic and international students, host nationals, and co-nationals; social connectedness (i.e., a subjective awareness of being in a close relationship with the social world; Lee and Robbins, 1998 ; and integrative motivation (i.e., a positive affective disposition towards the host community; Yu, 2013 .

Host-language proficiency predicts academic (Hirai et al., 2015 ; Yu, 2013 ), psychological (Hirai et al., 2015 ; Rui and Wang, 2015 ), and sociocultural adaptation (Brown, 2009 ; Duru and Poyrazli, 2011 ), confirming the acculturation theory (Ward et al., 2001 ). However, although some studies (Hirai et al., 2015 ; Yu, 2013 ) confirmed the impact of host-language proficiency on academic adaptation, they found no such impact on sociocultural adaptation. Yu’s ( 2013 ) study reported that sociocultural adaptation depends on academic adaptation rather than on host-language proficiency. Moreover, host-language proficiency increases the students’ knowledge of the host culture, reduces their uncertainty, and promotes intercultural communication (Gallagher, 2013 ; Rui and Wang, 2015 ), supporting the central aspects of the AUM theory (Gudykunst, 2005 ).

In turn, by enabling communication with academics and peers, second-language proficiency promotes academic (Yu and Shen, 2012 ) and sociocultural adaptation, as well as social satisfaction (Perrucci and Hu, 1995 ). It also increases the students’ willingness to communicate in non-academic contexts. This willingness mediates the relationship between second-language proficiency and cross-cultural difficulties among Asian students in England (Gallagher, 2013 ). This finding may explain inconclusive results concerning the relationship between second-language proficiency and cultural adaptation. It appears that second-language proficiency alone is insufficient for successful adaptation. This proficiency should be coupled with the students’ willingness to initiate intercultural communication to cope with communication and cultural difficulties, which is compatible with both the AUM theory and Kim’s ( 2001 ) communication and cross-cultural adaptation theory.

As mentioned before, host-language proficiency facilitates adaptation through social interactions. Research demonstrates that communication with domestic students predicts academic satisfaction (Perrucci and Hu, 1995 ) and academic adaptation (Yu and Shen, 2012 ), confirming Kim’s ( 2001 ) theory. Moreover, the frequency of interaction (Zimmermann, 1995 ) and direct communication with host nationals (Rui and Wang, 2015 ) predict adaptation and reduce uncertainty, supporting the AUM theory. Zhang and Goodson ( 2011 ) found that social interactions with host nationals mediate the relationship between adherence to the host culture and sociocultural adaptation difficulties, confirming the acculturation theory (Berry, 1997 ), the intergroup contact theory (Allport, 1954 ; Pettigrew, 2008 ), and the culture learning approach in acculturation theory (Ward et al., 2001 ).

In line with the intergroup contact theory, social connectedness with host nationals predicts psychological and sociocultural adaptation (e.g., Hirai et al., 2015 ; Zhang and Goodson, 2011 ), confirming the sojourner adjustment framework (Church, 1982 ) and extending the acculturation framework (Ward and Kennedy, 1999 ) that recognizes the relevance of social connectedness for sociocultural adaptation only.

Research on interactions with co-nationals has produced inconclusive results. Some qualitative studies (Pitts, 2009 ) revealed that communication with co-nationals enhances students’ sociocultural adaptation and psychological and functional fitness for interacting with host nationals. Consistent with Kim’s ( 2001 ) theory, such communication may be a source of instrumental and emotional support for students when locals are not interested in contacts with them (Brown, 2009 ). Nonetheless, Pedersen et al. ( 2011 ) found that social interactions with co-nationals may cause psychological adjustment problems (e.g., homesickness), contradicting the acculturation theory (Ward and Kennedy, 1994 ), or increase their uncertainty (Rui and Wang, 2015 ), supporting the AUM theory.

Avenues for future research

We addressed research question 5 regarding future research directions through a content analysis of the 31 most impactful articles in the field. Importantly, all 20 trending articles listed in Table 1 were contained in the set of 31 articles. This outcome confirms the relevance of the results of the content analysis. We used these results as the basis for formulating the research questions we believe should be addressed within each of the two research streams. These questions are listed in Table 3 .

Research has focused primarily on the experience of Asian students in Anglophone countries (16 out of 31 most impactful articles), with Chinese students’ integration being the motor theme. This is not surprising given that Asian students account for 58% of all international students worldwide (OECD, 2021b ). In addition, Anglophone countries have been the top host destinations for the last two decades. The USA, the UK, and Australia hosted 49% of international students in 2000, while the USA, the UK, Canada, and Australia hosted 47% of international students in 2020 (Project Atlas, 2020 ). This fact raises the question of the generalizability of the research results across cultural contexts, especially given the previously identified cultural variation in student adaptation (Fritz et al., 2008 ). Thus, it is important to study the experiences of students in underexplored non-Anglophone host destinations that are currently gaining in popularity, such as China, hosting 9% of international students worldwide in 2019, France, Japan, or Spain (Project Atlas, 2020 ). Furthermore, future research in various non-Anglophone countries could precisely define the role of English as a lingua franca vs. host-language proficiency in international students’ experience.

The inconsistent results concerning the effects of communication with co-nationals on student adaptation (e.g., Pedersen et al., 2011 ; Pitts, 2009 ) indicate that more contextualized research is needed to determine if such communication is a product of or a precursor to adaptation difficulties (Pedersen et al., 2011 ). Given the lack of confirmation of the acculturation theory (Ward and Kennedy, 1994 ) or the communication and cross-cultural adaptation theory (Kim, 2001 ) in this regard, future research could cross-check the formation of students’ social networks with their adaptation trajectories, potentially using other theories such as social network theory to explain the contradictory results of empirical research.

Zhang and Goodson ( 2011 ) showed that social connectedness and social interaction with host nationals predict both psychological and sociocultural adaptation. In contrast, the sojourner adjustment framework (Ward and Kennedy, 1999 ) considered their impact on sociocultural adaptation only. Thus, future research should conceptualize the interrelationships among social interactions in the host country and various adaptation domains (psychological, sociocultural, and academic) more precisely.

Some studies (Brown, 2009 ; Gallagher, 2013 ; Rui and Wang, 2015 ) confirm all of the major adaptation theories in that host-language proficiency increases cultural knowledge and the acquisition of social skills, reduces uncertainty and facilitates intercultural communication. Nevertheless, the impact of language on sociocultural adaptation appears to be a complex issue. Our content analysis indicated that sociocultural adaptation may be impacted by academic adaptation (Yu, 2013 ) or does not occur when students do not engage in meaningful interactions with host nationals (Ortaçtepe, 2013 ). To better capture the positive sociocultural adaptation outcomes, researchers should take into account students’ communication motivations, together with other types of adaptation that may determine sociocultural adaptation.

Next, in view of some research suggesting the mediating role of second-language proficiency (Yang et al., 2006 ), contacts with host nationals (Swami et al., 2010 ), and students’ global competence (Meng et al., 2018 ) in their adaptation, future research should consider other non-language-related factors such as demographic, sociocultural, and personality characteristics in student adaptation models.

Finally, the conceptual map of the field established the experiences of medical students and the learning environment as an emerging research agenda. We expect that future research will focus on the experience of other types of students such as management or tourism students who combine studies with gaining professional experience in their fields. In terms of the learning environment and given the development and growing importance of online learning as a result of the Covid-19 pandemic, future research should explore the effects of remote communication, both synchronous and asynchronous, in online learning on students’ adaptation and well-being.

This article offers an objective approach to reviewing the current state of the literature on language and communication in student adaptation by conducting a bibliometric analysis of 313 articles and a content analysis of 31 articles identified as the driving force in the field. Only articles in English were included due to the authors’ inability to read the identified articles in Russian, Spanish, or Chinese. Future research could extend the data search to other languages.

This review found support for the effects of language of communication on student adaptation, confirming major adaptation theories. Nevertheless, it also identified inconsistent results concerning communication with co-nationals and the complex effects of communication with host nationals. Thus, we suggested that future research better captures the adaptation outcomes by conducting contextualized research in various cultural contexts, tracking the formation of students’ social networks, and precisely conceptualizing interrelations among social interactions in the host country and different adaptation domains. Researchers should also consider students’ communication motivations and the mediating role of non-language-related factors in student adaptation models.

Akhtar, M., & Kröner-Herwig, B. (2015). Acculturative stress among international students in context of socio-demographic variables and coping styles. Current Psychology, 34 (4), 803–815. https://doi.org/10.1007/s12144-015-9303-4

Article   Google Scholar  

Allport, G. W. (1954). The nature of prejudice . Perseus Books.

Alon, I., Anderson, J., Munim, Z. H., & Ho, A. (2018). A review of the internationalization of Chinese enterprises. Asia Pacific Journal of Management, 35 (3), 573–605. https://doi.org/10.1007/s10490-018-9597-5

Anderson, L. E. (1994). A new look at an old construct: Cross-cultural adaptation. International Journal of Intercultural Relations, 18 (3), 293–328. https://doi.org/10.1016/0147-1767(94)90035-3

Andrade, M. S. (2006). International students in English-speaking universities. Journal of Research in International Education, 5 (2), 131–154. https://doi.org/10.1177/1475240906065589

Benzie, H. J. (2010). Graduating as a “native speaker”: International students and English language proficiency in higher education. Higher Education Research and Development, 29 (4), 447–459. https://doi.org/10.1080/07294361003598824

Berry, J. W. (1997). Immigration, acculturation, and adaptation. Applied Psychology, 46 (1), 5–34. https://doi.org/10.1111/j.1464-0597.1997.tb01087.x

Berry, J. W. (2005). Acculturation: Living successfully in two cultures. International Journal of Intercultural Relations, 29 (6), 697–712. https://doi.org/10.1016/j.ijintrel.2005.07.013

Black, J. S. (1990). The relationship of personal characteristics with the adjustment of Japanese expatriate managers. Management International Review, 30 (2), 119–134. https://doi.org/10.2307/40228014

Bretas, V. P. G., & Alon, I. (2021). Franchising research on emerging markets: Bibliometric and content analyses. Journal of Business Research, 133 , 51–65. https://doi.org/10.1016/j.jbusres.2021.04.067

Brown, L. (2009). Using an ethnographic approach to understand the adjustment journey of international students at a university in England. Advances in Culture, Tourism and Hospitality Research, 3 , 101–141. https://doi.org/10.1108/S1871-3173(2009)0000003007

Burr, V. (2006). An introduction to social constructionism . Routledge.

Book   Google Scholar  

Campbell, J., & Li, M. (2008). Asian students’ voices: An empirical study of Asian students’ learning experiences at a New Zealand University. Journal of Studies in International Education, 12 (4), 375–396. https://doi.org/10.1177/1028315307299422

Cao, C., Zhu, C., & Meng, Q. (2016). An exploratory study of inter-relationships of acculturative stressors among Chinese students from six European union (EU) countries. International Journal of Intercultural Relations, 55 , 8–19. https://doi.org/10.1016/j.ijintrel.2016.08.003

Church, A. T. (1982). Sojourner adjustment. Psychological Bulletin, 91 (3), 540–572. https://doi.org/10.1037/0033-2909.91.3.540

Cross, S. E. (1995). Self-construals, coping, and stress in cross-cultural adaptation. Journal of Cross-Cultural Psychology, 26 (6), 673–697. https://doi.org/10.1177/002202219502600610

Donthu, N., Kumar, S., Ranaweera, C., Sigala, M., & Sureka, R. (2020). Journal of Service Theory and Practice at age 30: Past, present and future contributions to service research. Journal of Service Theory and Practice, 31 (3), 265–295. https://doi.org/10.1108/JSTP-10-2020-0233

Duru, E., & Poyrazli, S. (2011). Perceived discrimination, social connectedness, and other predictors of adjustment difficulties among Turkish international students. International Journal of Psychology, 46 (6), 446–454. https://doi.org/10.1080/00207594.2011.585158

Fritz, M. V., Chin, D., & DeMarinis, V. (2008). Stressors, anxiety, acculturation and adjustment among international and North American students. International Journal of Intercultural Relations, 32 (3), 244–259. https://doi.org/10.1016/j.ijintrel.2008.01.001

Gallagher, H. C. (2013). Willingness to communicate and cross-cultural adaptation: L2 communication and acculturative stress as transaction. Applied Linguistics, 34 (1), 53–73. https://doi.org/10.1093/applin/ams023

Garfield, E., Paris, S. W., & Stock, W. G. (2006). HistCite™ : A software tool for informetric analysis of citation linkage. Information, 57 (8), 391–400.

Google Scholar  

Gudykunst, W. B., & Hammer, M. R. (1988). Strangers and hosts—An uncertainty reduction based theory of intercultural adaptation. In Y. Y. Kim & W. B. Gudykunst (Eds.), Cross-cultural adaptation: Current approaches (Vol. 11, pp. 106–139). Sage.

Gudykunst, W. B. (2005). An anxiety/uncertainty management (AUM) theory of strangers’ intercultural adjustment. In W. B. Gudykunst (Ed.), Theorizing about intercultural communication (pp. 419–457). Sage.

Hirai, R., Frazier, P., & Syed, M. (2015). Psychological and sociocultural adjustment of first-year international students: Trajectories and predictors. Journal of Counseling Psychology, 62 (3), 438–452. https://doi.org/10.1037/cou0000085

Hope, J. (2020). Be aware of how COVID-19 could impact international students. The Successful Registrar, 20 (3), 1–8. https://doi.org/10.1002/tsr.30708

Hotta, J., & Ting-Toomey, S. (2013). Intercultural adjustment and friendship dialectics in international students: A qualitative study. International Journal of Intercultural Relations, 37 (5), 550–566. https://doi.org/10.1016/j.ijintrel.2013.06.007

Jackson, J. (2015). Becoming interculturally competent: Theory to practice in international education. International Journal of Intercultural Relations, 48 , 91–107. https://doi.org/10.1016/j.ijintrel.2015.03.012

Jing, X., Ghosh, R., Sun, Z., & Liu, Q. (2020). Mapping global research related to international students: A scientometric review. Higher Education, 80 (3), 415–433. https://doi.org/10.1007/S10734-019-00489-Y

Khawaja, N. G., & Stallman, H. M. (2011). Understanding the coping strategies of international students: A qualitative approach. Journal of Psychologists and Counsellors in Schools, 21 (2), 203–224. https://doi.org/10.1375/ajgc.21.2.203

Kim, Y. Y. (2001). Becoming intercultural: An integrative theory of communication and cross-cultural adaptation . Sage.

Kramsch, C. (1998). Language and culture . Oxford University Press.

Lee, R. M., & Robbins, S. B. (1998). The relationship between social connectedness and anxiety, self-esteem, and social identity. Journal of Counseling Psychology, 45 (3), 338–345. https://doi.org/10.1037/0022-0167.45.3.338

Marginson, S. (2014). Student self-formation in international education. Student Self-Formation in International Education, 18 (1), 6–22. https://doi.org/10.1177/1028315313513036

Meng, Q., Zhu, C., & Cao, C. (2018). Chinese international students’ social connectedness, social and academic adaptation: The mediating role of global competence. Higher Education, 75 (1), 131–147. https://doi.org/10.1007/s10734-017-0129-x

Neuendorf, K. A. (2002). The content analysis guidebook (2nd ed.). Sage.

OECD (2021a). Education at a Glance 2021: OECD indicators . Paris: OECD Publishing. https://doi.org/10.1787/b35a14e5-en .

OECD (2021b). What is the profile of internationally mobile students? https://doi.org/10.1787/5A49E448-EN

Ortaçtepe, D. (2013). “This is called free-falling theory not culture shock!”: A narrative inquiry on second language socialization. Journal of Language, Identity and Education, 12 (4), 215–229. https://doi.org/10.1080/15348458.2013.818469

Pedersen, E. R., Neighbors, C., Larimer, M. E., & Lee, C. M. (2011). Measuring sojourner adjustment among American students studying abroad. International Journal of Intercultural Relations, 35 (6), 881–889. https://doi.org/10.1016/j.ijintrel.2011.06.003

Perrucci, R., & Hu, H. (1995). Satisfaction with social and educational experiences among international graduate students. Research in Higher Education, 36 (4), 491–508. https://doi.org/10.1007/BF02207908

Pettigrew, T. F. (2008). Future directions for intergroup contact theory and research. International Journal of Intercultural Relations, 32 (3), 187–199. https://doi.org/10.1016/J.IJINTREL.2007.12.002

Piller, I. (2007). Linguistics and Intercultural Communication. Language and Linguistics Compass, 1 (3), 208–226. https://doi.org/10.1111/j.1749-818X.2007.00012.x

Pitts, M. J. (2009). Identity and the role of expectations, stress, and talk in short-term student sojourner adjustment: An application of the integrative theory of communication and cross-cultural adaptation. International Journal of Intercultural Relations, 33 (6), 450–462. https://doi.org/10.1016/j.ijintrel.2009.07.002

Project Atlas . (2020).  https://iie.widen.net/s/rfw2c7rrbd/project-atlas-infographics-2020 . Accessed 15 September 2021.

Ruble, R. A., & Zhang, Y. B. (2013). Stereotypes of Chinese international students held by Americans. International Journal of Intercultural Relations, 37 (2), 202–211. https://doi.org/10.1016/j.ijintrel.2012.12.004

Rui, J. R., & Wang, H. (2015). Social network sites and international students’ cross-cultural adaptation. Computers in Human Behavior, 49 , 400–411. https://doi.org/10.1016/j.chb.2015.03.041

Sam, D. L. (2001). Satisfaction with life among international students: An exploratory study. Social Indicators Research, 53 (3), 315–337. https://doi.org/10.1023/A:1007108614571

Sawir, E., Marginson, S., Forbes-Mewett, H., Nyland, C., & Ramia, G. (2012). International student security and English language proficiency. Journal of Studies in International Education, 16 (5), 434–454. https://doi.org/10.1177/1028315311435418

Searle, W., & Ward, C. (1990). The prediction of psychological and sociocultural adjustment during cross-cultural transitions. International Journal of Intercultural Relations, 14 (4), 449–464. https://doi.org/10.1016/0147-1767(90)90030-Z

Shi, X. (2011). Negotiating power and access to second language resources: A study on short-term Chinese MBA students in America. Modern Language Journal, 95 (4), 575–588. https://doi.org/10.1111/j.1540-4781.2011.01245.x

Smith, R. A., & Khawaja, N. G. (2011). A review of the acculturation experiences of international students. International Journal of Intercultural Relations, 35 (6), 699–713. https://doi.org/10.1016/j.ijintrel.2011.08.004

Swami, V., Arteche, A., Chamorro-Premuzic, T., & Furnham, A. (2010). Sociocultural adjustment among sojourning Malaysian students in Britain: A replication and path analytic extension. Social Psychiatry and Psychiatric Epidemiology, 45 (1), 57–65. https://doi.org/10.1007/s00127-009-0042-4

Trentman, E. (2013). Imagined communities and language learning during study abroad: Arabic Learners in Egypt. Foreign Language Annals, 46 (4), 545–564. https://doi.org/10.1111/flan.12054

UIS Statistics . (2021).  http://data.uis.unesco.org/Index.aspx?queryid=172# . Accessed 10 December 2021.

Volet, S., & Jones, C. (2012). Cultural transitions in higher education: Individual adaptation, transformation and engagement. Advances in Motivation and Achievement, 17 , 241–284. https://doi.org/10.1108/S0749-7423(2012)0000017012

Wang, Q., & Hannes, K. (2014). Academic and socio-cultural adjustment among Asian international students in the Flemish community of Belgium: A photovoice project. International Journal of Intercultural Relations, 39 (1), 66–81. https://doi.org/10.1016/j.ijintrel.2013.09.013

Ward, C., Bochner, S., & Furnham, A. (2001). The psychology of culture shock (2nd ed.). Routledge.

Ward, C., & Kennedy, A. (1993). Where’s the “culture” in cross-cultural transition? Comparative studies of sojourner adjustment. Journal of Cross-Cultural Psychology, 24 (2), 221–249. https://doi.org/10.1177/0022022193242006

Ward, C., & Kennedy, A. (1994). Acculturation strategies, psychological adjustment, and sociocultural competence during cross-cultural transitions. International Journal of Intercultural Relations, 18 (3), 329–343. https://doi.org/10.1016/0147-1767(94)90036-1

Ward, C., & Kennedy, A. (1999). The measurement of sociocultural adaptation. International Journal of Intercultural Relations, 23 (4), 659–677. https://doi.org/10.1016/S0147-1767(99)00014-0

Yang, R. P. J., Noels, K. A., & Saumure, K. D. (2006). Multiple routes to cross-cultural adaptation for international students: Mapping the paths between self-construals, English language confidence, and adjustment. International Journal of Intercultural Relations, 30 (4), 487–506. https://doi.org/10.1016/j.ijintrel.2005.11.010

Ying, Y., & Liese, L. H. (1994). Initial adjustment of Taiwanese students to the United States: The impact of postarrival variables. Journal of Cross-Cultural Psychology, 25 (4), 466–477. https://doi.org/10.1177/0022022194254003

Young, T. J., & Schartner, A. (2014). The effects of cross-cultural communication education on international students’ adjustment and adaptation. Journal of Multilingual and Multicultural Development, 35 (6), 547–562. https://doi.org/10.1080/01434632.2014.884099

Yu, B. (2013). Asian international students at an Australian university: Mapping the paths between integrative motivation, competence in L2 communication, cross-cultural adaptation and persistence with structural equation modelling. Journal of Multilingual and Multicultural Development, 34 (7), 727–742. https://doi.org/10.1080/01434632.2013.796957

Yu, B., & Shen, H. (2012). Predicting roles of linguistic confidence, integrative motivation and second language proficiency on cross-cultural adaptation. International Journal of Intercultural Relations, 36 (1), 72–82. https://doi.org/10.1016/j.ijintrel.2010.12.002

Zhang, J., & Goodson, P. (2011). Acculturation and psychosocial adjustment of Chinese international students: Examining mediation and moderation effects. International Journal of Intercultural Relations, 35 (5), 614–627. https://doi.org/10.1016/j.ijintrel.2010.11.004

Zimmermann, S. (1995). Perceptions of intercultural communication competence and international student adaptation to an American campus. Communication Education, 44 (4), 321–335. https://doi.org/10.1080/03634529509379022

Zupic, I., & Čater, T. (2015). Bibliometric methods in management and organization. Organizational Research Methods, 18 (3), 429–472. https://doi.org/10.1177/1094428114562629

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Acknowledgements

We thank the anonymous reviewers for their insightful comments and suggestions.

This research is supported by the Polish National Agency for Academic Exchange grant “Exploring international students’ experiences across European and non-European contexts” [grant number PPN/BEK/2019/1/00448/U/00001] to Michał Wilczewski.

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Wilczewski, M., Alon, I. Language and communication in international students’ adaptation: a bibliometric and content analysis review. High Educ 85 , 1235–1256 (2023). https://doi.org/10.1007/s10734-022-00888-8

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Strategies for overcoming language barriers in research

• Rory Meyers College of Nursing
• New York University
• Urban Initiative

Research output : Contribution to journal › Article › peer-review

Aim: This paper seeks to describe best practices for conducting cross-language research with individuals who have a language barrier. Design: Discussion paper. Data Sources: Research methods papers addressing cross-language research issues published between 2000–2017. Implications for Nursing: Rigorous cross-language research involves the appropriate use of interpreters during the research process, systematic planning for how to address the language barrier between participant and researcher and the use of reliably and validly translated survey instruments (when applicable). Biases rooted in those who enter data into “big data” systems may influence data quality and analytic approaches in large observational studies focused on linking patient language preference to health outcomes. Conclusion: Cross-language research methods can help ensure that those individuals with language barriers have their voices contributing to the evidence informing healthcare practice and policies that shape health services implementation and financing. Understanding the inherent conscious and unconscious biases of those conducting research with this population and how this may emerge in research studies is also an important part of producing rigorous, reliable, and valid cross-language research. Impact: This study synthesized methodological recommendations for cross-language research studies with the goal to improve the quality of future research and expand the evidence-base for clinical practice. Clear methodological recommendations were generated that can improve research rigor and quality of cross-language qualitative and quantitative studies. The recommendations generated here have the potential to have an impact on the health and well-being of migrants around the world.

• asylum seeker
• language barrier
• translations
• undocumented immigrants

ASJC Scopus subject areas

• General Nursing

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• 10.1111/jan.14007

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• Link to publication in Scopus
• Link to citation list in Scopus

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• Language Medicine & Life Sciences 42%
• Healthcare Financing Medicine & Life Sciences 9%
• Data Science Medicine & Life Sciences 9%
• Big Data Medicine & Life Sciences 9%
• Data Systems Medicine & Life Sciences 8%
• Psychology Unconscious Medicine & Life Sciences 8%
• Patient Preference Medicine & Life Sciences 7%
• Data Accuracy Medicine & Life Sciences 7%

T1 - Strategies for overcoming language barriers in research

AU - Squires, Allison

AU - Sadarangani, Tina

AU - Jones, Simon

N1 - Funding Information: Funding information This paper was informed by research funded by the United States’ Agency for Health Care Research and Quality, R01HS23593. Publisher Copyright: © 2019 John Wiley & Sons Ltd

PY - 2019/1/1

Y1 - 2019/1/1

N2 - Aim: This paper seeks to describe best practices for conducting cross-language research with individuals who have a language barrier. Design: Discussion paper. Data Sources: Research methods papers addressing cross-language research issues published between 2000–2017. Implications for Nursing: Rigorous cross-language research involves the appropriate use of interpreters during the research process, systematic planning for how to address the language barrier between participant and researcher and the use of reliably and validly translated survey instruments (when applicable). Biases rooted in those who enter data into “big data” systems may influence data quality and analytic approaches in large observational studies focused on linking patient language preference to health outcomes. Conclusion: Cross-language research methods can help ensure that those individuals with language barriers have their voices contributing to the evidence informing healthcare practice and policies that shape health services implementation and financing. Understanding the inherent conscious and unconscious biases of those conducting research with this population and how this may emerge in research studies is also an important part of producing rigorous, reliable, and valid cross-language research. Impact: This study synthesized methodological recommendations for cross-language research studies with the goal to improve the quality of future research and expand the evidence-base for clinical practice. Clear methodological recommendations were generated that can improve research rigor and quality of cross-language qualitative and quantitative studies. The recommendations generated here have the potential to have an impact on the health and well-being of migrants around the world.

AB - Aim: This paper seeks to describe best practices for conducting cross-language research with individuals who have a language barrier. Design: Discussion paper. Data Sources: Research methods papers addressing cross-language research issues published between 2000–2017. Implications for Nursing: Rigorous cross-language research involves the appropriate use of interpreters during the research process, systematic planning for how to address the language barrier between participant and researcher and the use of reliably and validly translated survey instruments (when applicable). Biases rooted in those who enter data into “big data” systems may influence data quality and analytic approaches in large observational studies focused on linking patient language preference to health outcomes. Conclusion: Cross-language research methods can help ensure that those individuals with language barriers have their voices contributing to the evidence informing healthcare practice and policies that shape health services implementation and financing. Understanding the inherent conscious and unconscious biases of those conducting research with this population and how this may emerge in research studies is also an important part of producing rigorous, reliable, and valid cross-language research. Impact: This study synthesized methodological recommendations for cross-language research studies with the goal to improve the quality of future research and expand the evidence-base for clinical practice. Clear methodological recommendations were generated that can improve research rigor and quality of cross-language qualitative and quantitative studies. The recommendations generated here have the potential to have an impact on the health and well-being of migrants around the world.

KW - asylum seeker

KW - immigrants

KW - language barrier

KW - methods

KW - nurses

KW - nursing

KW - refugee

KW - translations

KW - undocumented immigrants

UR - http://www.scopus.com/inward/record.url?scp=85067899110&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85067899110&partnerID=8YFLogxK

U2 - 10.1111/jan.14007

DO - 10.1111/jan.14007

M3 - Article

C2 - 30950104

AN - SCOPUS:85067899110

SN - 0309-2402

JO - Journal of Advanced Nursing

JF - Journal of Advanced Nursing

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Language barriers between nurses and patients: A scoping review

Lauren gerchow.

a New York University Rory Meyers College of Nursing, 433 1st Ave, New York, NY, USA

Larissa R. Burka

Sarah miner.

b St. John Fisher College Wegmans School of Nursing, 3690 East Ave, Rochester, NY, USA

Allison Squires

CRediT authorship contribution statement

Global migration and linguistic diversity are at record highs, making healthcare language barriers more prevalent. Nurses, often the first contact with patients in the healthcare system, can improve outcomes including safety and satisfaction through how they manage language barriers. This review aimed to explore how research has examined the nursing workforce with respect to language barriers.

A systematic scoping review of the literature was conducted using four databases. An iterative coding approach was used for data analysis. Study quality was appraised using the CASP checklists.

48 studies representing 16 countries were included. Diverse healthcare settings were represented, with the inpatient setting most commonly studied. The majority of studies were qualitative. Coding produced 4 themes: (1) Interpreter Use/Misuse, (2) Barriers to and Facilitators of Quality Care, (3) Cultural Competence, and (4) Interventions.

Conclusion:

Generally, nurses noted like experiences and applied similar strategies regardless of setting, country, or language. Language barriers complicated care delivery while increasing stress and workload.

Practice Implications:

This review identified gaps which future research can investigate to better support nurses working through language barriers. Similarly, healthcare and government leaders have opportunities to enact policies which address bilingual proficiency, workload, and interpreter use.

1. Introduction

Global migration is making countries around the world increasingly linguistically diverse and language barriers between healthcare providers and patients more prevalent [ 1 ]. Globally, migration patterns have changed significantly in recent years, and the number of displaced people seeking refuge in foreign nations is at a record high [ 2 ]. These changing demographics challenge health systems to provide care when a language barrier is present. Language barriers affect healthcare access [ 3 , 4 ], patient satisfaction [ 5 ], and safety [ 6 ] and require integrating interpreter services into both the process of care delivery and the therapeutic relationship in order to minimize disparities [ 7 ]. Research about language barriers in healthcare has grown substantially in the last twenty years, but it is notably focused on physicians and lacking about nurses [ 8 ].

Since nurses are often the first professional point of contact for patients in healthcare systems, how they address language barriers at that first juncture and throughout the encounter influences patient experiences and outcomes. Research shows that managing language barriers during admission and discharge decreases length of stay [ 9 ], errors, and readmissions [ 10 ].

1.1. Objective

With these demographic and workforce trends in mind, we sought to explore how research examines the global nursing workforce facing language barriers. Goals of this study include highlighting the current state of the science and identifying gaps in the literature to make recommendations for future research around language barriers.

We conducted a scoping review of the literature that studied the nursing workforce with regard to language barriers. Scoping reviews address research questions with emerging evidence, where the dearth of randomized controlled trials makes other systematic review methods difficult [ 11 ]. This methodology identifies gaps in existing literature and clarifies future research questions [ 12 , 13 ]. With these criteria in mind, we chose to undertake a scoping review following the framework set by Arksey and O’Malley [ 12 ] to meet our goals.

2.1. Scoping review framework

The Arksey and O’Malley scoping review framework utilizes a five-stage, iterative approach [ 12 ]. In the first stages, researchers identify a research question and undertake a systematic, comprehensive search. In the study screening stage, inclusion and exclusion criteria are applied, with the possibility that criteria change as authors develop greater familiarity with the breadth of the literature. Following screening, researchers organize and sort the data to enable theme identification, often using a chart or table. While this stage can be guided by a framework which emphasizes certain aspects of the literature, uniform categorization is not always achievable due to the diversity in study design and clarity. In the final stage, the organized data is summarized and presented to illuminate the breadth of literature on a topic rather than to weight the evidence by quality or outcomes measurements.

2.2. Literature search

2.2.1. inclusion and exclusion criteria.

We began with limiting our search criteria to studies which examined language barriers in populations of registered nurses (RN), practical nurses, and nurse practitioners (NP). We excluded studies which addressed language barriers from the patient perspective and studies with mixed provider populations without distinct findings on nurses. After full-text screening, we excluded NP studies, to further narrow the research question. NPs work with patients in different contexts than RNs, and NP-specific findings merit their own review. We also opted to exclude studies of midwives since there are both nurse-midwives and midwives who have different educational paths and scopes of practice, thus concluding a separate study would be needed specific to that cadre.

2.2.2. Search strategy

Authors LG, LB and SM conducted a literature search using the PubMed, Cumulative Index to Nursing and Allied Health (CINAHL), Web of Science, and PsycINFO databases with combinations of the terms “nurs*”, “language barrier”, “limited English proficiency”, “interpreter”, “immigrant”, and “health literacy” for research studies published in English, Spanish, or Portuguese, reflecting the language capacities of the team members. We included studies published from 2010 through November 2019 to reflect recent global migration trends. To enhance search rigor and follow the Arksey and O’Malley comprehensive scoping review search guidelines [ 12 ], we searched reference lists and a journal special edition specific to communication concerns in healthcare. LG and LB conducted both title and abstract and full-text screening, applying the above inclusion and exclusion criteria. Any disagreements were resolved by either SM or AS.

The original searched returned 2,784 titles, and selection was managed through Covidence. Duplicate articles (579) were removed leaving 2,205 remaining titles. Following title and abstract screening, 101 articles remained. Full-text data extraction eliminated an additional 53 publications, most of which did not report distinct RN findings (17) or did not address language barriers (12). The decision to exclude NP and midwife studies through the iterative process eliminated 4 full-text articles. Fig. 1 reports the search strategy and lists all reasons for full-text exclusion.

Search Screening Process.

2.3. Data analysis

Due to the volume of articles included in the review, the analytic process naturally involved conducting a general thematic analysis using an iterative coding approach. When documents are the “data” for a study, general thematic analysis is used to understand both content and context of the data sources [ 14 ]. LG and LB reviewed content of the selected articles then extracted and reduced data to identify key themes consistent with the review objectives, with AS providing a confirmatory review of the analysis.Themes were organized into a table to facilitate comparison and synthesis and conclusions were reached via consensus. All articles were initially analyzed together, with no distinction between country or practice setting. Findings unique to specific cadres of nurses or commonalities between settings were then extracted.

2.4. Critical appraisal

The Critical Appraisal Skills Programme (CASP) qualitative, cohort study, and case control study checklists were used to appraise quality depending on study design [ 15 ]. LG appraised all studies, and any disagreements were discussed between the authors. Study quality was not a factor in inclusion or exclusion criteria, as per the Arksey and O’Malley scoping review framework. The team, however, deemed it important to provide quality assessments of the included studies for the purpose of this review.

Forty-eight articles formed the final sample for this review. The studies represent a total of 4,766 nurses working in 16 countries, 480 other providers, 19,787 patients or patient encounters, and reflect a broad range of methodologies and study populations. Table 1 summarizes study methods, population, setting, and geographic location. Table 2 lists study findings, and Table 3 summarizes strengths and weaknesses.

Design, Context, Population and Geographic Location by Study

Descriptive Summary of Methods and Findings by Study

Summary of Study Strengths and Weaknesses

The majority of studies (32/48) addressed language barriers directly in the research question, with the remaining studies investigating issues of culture or communication. RNs were analyzed alone in 26 studies. Twelve studies used mixed provider populations and 11 studies included patients, either observed or analyzed as a dyad with a provider or as a participant. Thirty of the studies were qualitative investigations 5 studies used mixed-methods, and the remaining 13 were quantitative studies with various designs.

The articles represented diverse inpatient and outpatient healthcare settings including emergency department, prison, school, inpatient psychiatric, nursing home and community health. Twenty-five studies analyzed encounters in the hospital setting. Geographically, sixteen countries were represented, with the majority of studies from the United States (13) and Scandinavia (11).

The analysis produced four themes: (1) Interpreter Use/Misuse, (2) Barriers to and Facilitators of Quality Care, (3) Cultural Competence, and (4) Interventions. The synthesis reflects the common complexities that nurses face globally due to language barriers and identifies nursing interventions aimed to improve outcomes.

3.1. Interpreter use/misuse

Nurse interaction with interpreters was a common theme throughout the literature. While experiences with interpreters varied, findings were similar across studies.

3.1.1. Accessibility and usability

The accessibility and usability of professional interpreters impacted care. The articles studied multiple methods of interpretation, including in-person, telephone, and video. Nurses consistently expressed difficulty in accessing interpreters [ 16 – 26 ] and usability issues with telephone translation [ 17 , 20 , 27 ]. Some nurses opted to use apps or websites when interpreters were unavailable [ 24 , 28 ], while others chose not to use an available professional interpreter [ 26 , 29 – 31 ]. When working with interpreters, nurses spoke to them, rather than patients, and those conversations were less personal than language concordant encounters [ 32 ]. Nurses also expressed concerns about interpreter translation accuracy [ 16 , 20 , 25 , 33 – 36 ].

Despite these difficulties, nurses described improved care when working in settings with adequate professional interpreter staffing [ 21 , 28 , 35 – 37 ]. Clinically, discharge planning [ 30 ], objective translation [ 25 ], and patient involvement in decision-making [ 28 ] improved when nurses accessed a professional interpreter. Interpreters also served as a cultural bridge [ 33 – 35 ] between nurses and their patients. Nurses generally preferred professional, in-person interpretation if available, but often relied on other communication methods.

3.1.2. Ad hoc interpreters

Ad hoc interpreters are uncertified translators, such as family or non-interpreter staff. Perceived insufficient interpreter access forced nurses to use ad hoc interpreters, including staff [ 16 , 23 , 28 , 30 , 36 , 38 , 39 ], family or friends [ 18 – 20 , 23 , 25 , 28 , 30 , 38 – 43 ], or in the case of school and prison nurses, bilingual peers[ 26 , 31 ]. Ad hoc interpreters led to quality issues around confidentiality [ 16 , 26 ], censoring of sensitive information [ 23 , 25 ], concerns about translation accuracy [ 16 , 20 , 25 , 33 , 34 , 36 , 44 ] and reliance on inadequate language skills [ 30 ]. For bilingual nurses specifically, the literature consistently highlighted concerns about workload and stress when assuming a dual nurse-interpreter role [ 23 , 27 , 36 , 45 ].

3.2. Barriers to and facilitators of quality care

The literature identified both barriers and facilitators either specific to the RN role or related to systems and policies that impacted the quality of care delivered by nurses to non-language concordant patients. Despite differences in care settings and geography, findings were similar across the literature.

3.2.1. Barriers

Nurses in various practice contexts both encountered and created barriers to high quality patient care. Descriptions of modified nursing care to patients with language barriers were common. For example, nurses feared non-language-concordant patients misunderstood call light importance [ 24 ] and described less frequent call light usage by non-language concordant patients [ 38 ]. Similarly, non-language-concordant patients spent less time with nurses [ 25 ], struggled to provide a detailed history [ 25 , 46 ] and had frequent uninterpreted encounters with nurses [ 17 , 30 ]. Nurses described poor communication with non-language concordant patients as potentially riskier than no communication with these patients at all [ 46 ]. Two studies further described how language barriers complicated end of life care [ 47 , 48 ].

Language barriers also impacted the nurse-patient relationship in ways participants perceived as negative and it was magnified in certain settings, including psychiatric ones [ 49 ], NICU [ 50 ], prehospital and ambulances [ 17 ], prisons [ 26 ], and maternal child community health [ 33 , 51 ]. Interpreters censored some patient information, such as poor treatment adherence, when translating nurse-patient encounters according to some nurses [ 52 ]. Nurses further worried that patients did not understand health-specific education [ 21 , 33 , 46 , 50 , 53 ]. These modifications to routine care impacted both patient relationships and care delivery, which ultimately may affect safety.

Workforce related barriers were identified in the literature in multiple contexts. Routine care of non-language-concordant patients, even with an interpreter, required extra time [ 20 – 23 , 27 , 34 , 37 , 38 , 45 , 50 , 53 , 54 ]. Nurses described a lack of leadership support around staffing, policies, and increased workload [ 18 , 20 , 36 , 45 , 50 ]. Similarly, nurses felt undertrained and unprepared to manage language barriers effectively [ 20 , 36 , 42 , 47 ]. Finally, gender limitations on visitation for pediatric patients forced nurses to communicate with non-language concordant mothers, despite language-concordance with the fathers [ 18 ].

3.2.2. Facilitators

The literature also identified nursing specific strategies, bedside tools, and workplace structure that helped nurses improve care delivery to non-language-concordant patients. Nurses found their years of work experience as beneficial to work around language barriers [ 45 , 55 ] or to work as both an interpreter and RN [ 30 ]. Bedside strategies included nonverbal communication [ 17 – 19 , 23 , 25 , 38 , 39 , 46 , 56 , 57 ] or using structured assessments [ 17 , 30 ]. All these actions added to nurse workload, regardless of setting.

Workforce variables also facilitated higher quality nursing care in multiple care contexts. Collaborative, consistent relationships with interpreters helped nurses improve relationships with non-language-concordant patients [ 28 , 35 , 48 ]. Nurses also described using time and effort to connect to and understand non-language-concordant patients to address nursing-specific needs like pain [ 21 ]. Similarly, nurses described personal growth and care-delivery improvements as a result of working with patients through a language barrier [ 37 ]. While some nurses described these behaviors as instinctual, others desired education from management regarding how to better serve these patients [ 18 , 50 ].

3.3. Cultural competence

Language and culture are linked, and nurses’ self-assessed skills in these areas affected how they perceived their care delivery. A nurse’s own culture, similar or not to a patient’s, impacted care delivery [ 18 – 20 , 23 , 36 , 39 , 42 , 48 , 50 , 53 , 58 ]. Nurses observed cultural beliefs impacting healthcare decisions or treatments [ 19 , 23 , 39 , 47 , 48 ] and described their own knowledge deficits that inhibited connection with patients and comprehension of their needs [ 36 , 42 , 50 , 59 ]. Some nurses expressed xenophobia [ 36 , 42 ], while others desired cultural sensitivity training [ 36 , 39 , 60 ]. The implicit and explicit ties between language and culture were apparent to the nurses, but their comfort with integrating them into care delivery appeared to vary as did their reasons for what shaped their comfort levels.

3.4. Interventions

Five of the studies involved the design or testing of interventions regarding nursing care of non-language-concordant patients. Four studies enhanced bedside communication through tools and technology [ 40 , 44 , 46 , 61 ]. Of these, two studies tested care improvements [ 40 , 61 ], while the others addressed tool design, feasibility, or acceptability. One study tested the impact an online cultural humility tool could have on nursing practice, finding significant self-assessed improvements in practice in post-testing [ 62 ]. Two studies facilitated a discussion around proposed tools to improve communication for non-language-concordant patients [ 24 , 46 ]. RNs in these studies found the use of symbols and pictures as innovative [ 24 ] and identified nursing-specific encounters where a bedside communication tool would be beneficial including responding to call lights, consenting for procedures, assessing neurologic status, and providing standard daily care such as toileting [ 46 ]. While the majority of the literature around nurses and language barriers was exploratory, these studies described interventions to address some of the barriers nurses identified in the qualitative data.

3.5. Critical appraisal

We reviewed the studies’ strengths and weaknesses identified through the CASP checklists. Common methodological concerns for qualitative papers centered around data analysis, with many studies providing little description of the analysis process [ 22 , 25 , 26 , 37 , 38 , 42 , 44 , 46 , 53 ] or researchers failing to reflect on their own experiences as a source of potential bias throughout the analysis process [ 16 , 20 , 23 , 25 , 26 , 32 – 35 , 37 , 45 , 49 , 52 , 53 , 56 ]. Nonetheless, some qualitative studies applied methods to add rigor, including triangulation, member checking, written audit trails and detailed coding descriptions [ 16 – 19 , 21 , 23 , 24 , 26 , 27 , 32 , 35 , 44 , 45 , 48 – 50 , 52 , 56 , 60 , 63 ]. Three articles, two from a single study, confirmed intercoder reliability using either Cohen’s kappa or Holsti’s method [ 18 , 32 , 52 ], an approach not always necessary in qualitative research and the subject of methodological debates.

The majority of quantitative studies were descriptive studies. The most common methodological concerns for these studies were samples that were predominantly or 100% female [ 21 , 47 , 58 , 62 ] or had survey response rates below 50% [ 41 , 47 , 55 ]. The latter is less concerning given methodological advances indicating that low response rates can still produce generalizable results [ 64 ]. Lastly, one study comparing providers’ use of Spanish language by skill level used self-assessed proficiency rather than verified testing [ 30 ]. Nonetheless, studies applied methods to improve study quality. Survey studies used pretesting, focus groups, detailed survey-development methodologies and pre-existing valid and reliable tools to enhance study rigor [ 28 , 29 , 40 , 47 , 55 , 58 ]. One study utilized random sampling [ 47 ], with the rest using convenience or purposive methods. Surprisingly, only two studies determined sample size with power analysis [ 29 , 62 ].

Importantly, the articles in the review did not equitably represent the breadth of settings where nurses practice. The majority of articles investigated hospital-based nurses. The lack of research about nurses practicing in non-hospital sites is concerning since language barriers can exist anywhere a nurse works and language resources available in nonhospital settings may differ in feasibility and accessibility. Similarly, the unique interactions and relationships between nurses and patients were not adequately addressed in mixed provider studies that did not separate findings by role.

4. Discussion and conclusion

4.1. discussion.

This review captures the recent evidence associated with nursing care in the presence of a language barrier. The body of literature highlights the linguistic complexities that nurses face from a global perspective and describes how culture, the role of the interpreter, and nursing strategies and tools impact care delivery, quality, and outcomes. A patient’s language preference that differs from a country’s official language is a key social risk factor and determinant of health. This study highlighted how nurses work with and around language barriers with patients and captured some of the complexity of those interactions. Findings across countries were similar, despite differences in migration trends or language- nurses facing language barriers desire to provide quality care but encounter many obstacles, regardless of setting, language, or country.

4.1.1. Interpreters

The presence of a professional interpreter has proven to mitigate health disparities through decreased errors and greater access and satisfaction [ 65 ]. Nurses in the included literature, however, struggled to access interpreters and expressed distrust in their skills. At the same time, policies around the provision of healthcare language services including training, certification and required use of interpreters, differ greatly between nations [ 66 ]. Even in countries with laws which ensure language-concordant healthcare, nurses in this review expressed concerns. Ad hoc interpreters are not an appropriate substitute in most circumstances due to concerns around confidentiality, translation error, and workload for bilingual staff. A lack of regulation of the interpreting industry more broadly may contribute the nurses’ concerns.

4.1.2. Workforce and workplace

Nurses expressed concern around role-specific patient interactions such as call-light usage, pain assessment, or patient education that differ when working through a language barrier. While nurses employed strategies to overcome those issues, concerns about patient safety and RN workload were described across the literature. Nurses asked for greater logistical support and role-specific education from management around cultural sensitivity and interpreter use in order to address the health disparity created by a language barrier. Despite similar findings across the literature around both the barriers to and facilitators of high quality nursing care, no standardized model of care delivery existed, even amongst nurses practicing in the same site or analyzed in the same study.

4.1.3. Limitations

Like all reviews, the limitations center on the quality of the search as well as how the authors mitigated their own biases. We adhered to Arksey and O’Malley’s methodological recommendations [ 12 ] to enhance rigor in the data evaluation, comparison, and reduction stages. The team conducting the study, however, were all registered nurses from the USA with varying levels of experience and three members of the team are bilingual RNs. One team member, however, did have extensive international nursing workforce research experience across 34 countries. While this helped the interpretation of our findings, the conclusions may reflect our biases that favor language concordant patient-provider encounters.

4.2. Conclusion

Even though the results of this review highlight the complexity and challenges nurses face due to language barriers, the more surprising result was how few studies involved nurses as the primary study population. A brief physician focused search in PubMed produced over 150 research studies, largely in primary care, as a comparison. While the findings from these physician-focused studies are generally similar to those of this review [ 67 – 69 ], nurses spend more time with patients than physicians [ 70 ] and have different roles in all settings. These differences merit individualized, RN-specific investigations regarding language barriers as well as interventions aside from interpreters that can enhance nurse-patient communication. In addition to testing interventions, additional qualitative data is needed from more geographic regions to ensure that the trends identified in this scoping review are applicable worldwide.

Patient-provider language barriers are global issues that affect all providers. Our study captured the lack of research focused on nurses and we suspect there is a dearth of research about other allied healthcare roles as well. The reduction of the risk for health disparities related to language barriers has to involve understanding the best methods for each role in order to bridge them. This study summarized and noted the commonalities and differences of nurse experiences when facing language barriers. More research and its translation into the workplace will enhance the precision of their practice with this population and contribute to disparities reduction.

4.3. Practice implications

The findings across care settings and countries have identified various implications for practice which apply to a global nursing population. Healthcare leadership and nursing management have an opportunity to create structural and staffing changes to reflect the demands nurses face when working with language barriers. Bilingual nurses with certified skills and nurses dually trained as interpreters are two options. For bilingual staff, leadership must ensure that their self-assessed language skills are adequate to meet patient needs. It is notable that no study addressed testing or certification of providers who chose to use their own language skills rather than an interpreter. This was true even for studies published in the US after the implementation of Section 1557 of the Affordable Care Act which required healthcare facilities to test provider language proficiency [ 71 ].

Proficiency testing in entry-level educational programs would certify language skills early in health professionals’ careers and potentially foster the appropriate use of interpreters long term. Entry-level testing via a nationally standardized program would also save costs for healthcare systems who bear the burden of language assessment. Development, testing, implementation, and evaluation of nursing specific protocols and policies around staffing and time management could help nurses address common concerns regarding the added workload that comes with working with patients with language barriers. Standardizing appropriate utilization of bilingual nurses in the workplace is critical so that serving as a dual-role interpreter does not supersede their nursing role.

Based on the findings, we have identified several opportunities for future research. First, research needs to confirm when the critical interactions during care delivery should require an interpreter and distinguish from those that do not. Second, we need to understand what is considered “acceptable” for basic communication since an interpreter cannot be present for RNs at all times. In addition, the qualitative findings in this review identified numerous areas which could be tested through quantitative interventions using nurse-patient dyads.

Similarly, continued investigation into the experiences of nurses working outside of the hospital setting is needed to fully understand the impact of cultural and language incongruencies, since their resources and patient relationships are distinct. The lack of research on mental health nurses is particularly significant. A 2016 systematic review showed that immigrants already use mental health services less than their native counterparts [ 72 ] and poor language services may be one explanation. More research examining mental health services delivery in the context of language barriers is needed. As global demographics continue to change, continued research on the role-specific impact of language barriers in health care and its translation into nursing practice is needed to both address the growing health disparity and to adhere to and inform policy.

Acknowledgment

This work was supported by the Agency for Healthcare Research and Quality, United States [R01HS023593].

Declaration of Competing Interest

Authors LG, LRB, and SM declare no conflicts of interest. Author AS declares the following:

• 2019 Consultant, Qualitative Methods, National Council of State Boards of Nursing, USA.
• 2016–18 Consultant, International Nurse Migration, Kings College London, London, UK.
• 2018 Consultant with travel grant, Survey Instrument Translation, Charles University, Prague, Czech Republic.
• 2018 Conference speaker honoraria, Yonsei University School of Nursing, Seoul, South Korea. −2015 to present, Principal, ABC Education Consultants LLC, New York, USA.

• Open access
• Published: 26 July 2021

Impacts of English language proficiency on healthcare access, use, and outcomes among immigrants: a qualitative study

• Mamata Pandey 1 ,
• R. Geoffrey Maina 2 ,
• Jonathan Amoyaw 3 ,
• Yiyan Li 2 ,
• Rejina Kamrul 4 ,
• C. Rocha Michaels 4 &
• Razawa Maroof 4  

BMC Health Services Research volume  21 , Article number:  741 ( 2021 ) Cite this article

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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.

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.

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.

Peer Review reports

Major immigrant-destination countries like the United States, Germany, Canada, and Australia admit a large share of immigrants from culturally and linguistically diverse countries [ 1 ]. According to the 2016 Canadian Census, foreign-born individuals make up more than one-fifth (21.9%) of the Canadian population, which is close to the highest level (22.3%), recorded in the 1921 Census [ 2 ]. Most immigrants to Canada come from countries like the Philippines, India, China, Nigeria, and Pakistan, where most citizens’ first language is neither English nor French [ 3 , 4 , 5 ]. Individuals without local language proficiency are more likely to have lower income, and face considerable challenges with economic and social integration [ 6 , 7 , 8 ]. These settlement challenges increase the risk of poor health outcomes among newcomers with limited language proficiency [ 9 ]. Newcomers also face inequities in healthcare settings [ 10 ]. Due to immigration requirements, most newcomers are healthier than the general population, an effect referred to as the “healthy immigrant effect.” This effect is observed to decline over time [ 11 , 12 , 13 ]. Limited language proficiency is associated with decline in self-reported health status of new immigrants during the first 4 years of stay in Canada [ 9 ].

The ability to speak the host country’s official language proficiently appears to be an essential determinant of health [ 13 , 14 , 15 , 16 ]. The ability to speak, read, and write in the local language is necessary to communicate with healthcare providers and interact in other social settings [ 17 , 18 , 19 ]. Language is consistently identified as a barrier for immigrants and refugees seeking, accessing, and using mental health services [ 11 , 12 , 15 , 20 ]. Lee and colleagues [ 21 ] argued that Chinese immigrant women are more likely to choose service providers who speak the same language. Marshall, Wong, Haggerty, and Levesque [ 4 ] observed that Chinese- and Punjabi-speaking individuals with limited English language proficiency might delay accessing healthcare to find providers who speak their language. In the absence of culture-specific words and due to stigma, individuals from some ethnics groups may have difficulty describing mental health conditions or describe them as somatic symptoms [ 12 , 22 , 23 , 24 ]. Lack of language support or culturally appropriate services can interfere with timely mental health diagnosis and/or utilization of mental health services [ 12 , 23 , 24 ].

Language-incongruent encounters within the healthcare system increase the risk of inadequate communications, misdiagnosis, medication errors and complications, and even death [ 15 , 19 , 25 ]. Studies indicate that language barriers adversely affect health outcomes, healthcare access, utilization and cost of healthcare services, health-providers’ effectiveness, and patient satisfaction and safety [ 15 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].

Aery and colleagues [ 34 ] argue that the rights that allow individuals access to language interpreters in the justice system are also applicable in the healthcare context. Without language assistance, individuals with language barriers cannot engage in their treatment, determine risks and benefits of suggested treatment, and/or provide informed consent [ 34 , 35 ]. Human rights legislations in Canada have provided a framework and highlight the necessity to provide language interpreters when needed, but these have not been implemented universally [ 35 ]. Some provinces in Canada have launched language interpretation services. These services include: the Language Services Toronto in Ontario, language services for French-Canadians offered by Winnipeg Health Region in Manitoba and CanTalk telephonic interpreter services approved by the Saskatchewan Health Authority in Saskatchewan [ 35 , 36 , 37 , 38 ]. Professional interpreter services are not covered under most provincial health policies and therefore might not be available in all jurisdictions [ 3 ]. In the absence of universal interpretation services across the country, healthcare providers rely on professional interpreters, interpreters from community-based organizations and/or ad hoc (untrained) interpreters such as family members, friends, and volunteers who lack understanding of medical terminology and disease [ 3 , 36 , 37 , 38 ]. Although the services of professional language interpreters are employed in many Canadian healthcare settings, reliance on ad hoc interpreters, is preponderant [ 35 ]. This is partly due to a lack of trained interpreters in the language required and new immigrants’ lack of knowledge about available language supports [ 10 ]. Providers are also not comfortable with interpreters as it is time consuming, and providers might have different expectations about the roles of interpreters [ 3 ]. The impacts of local language proficiency on immigrants’ health and well-being are relevant and have been studied in other major immigrant-destination countries such as Australia, the United Kingdom, the United States of America [ 15 , 17 , 25 , 32 ].

This topic is particularly relevant in the Canadian context as 72.5% of immigrants are reported to have a mother tongue other than English or French according to the 2016 Census [ 39 ]. Given the unique history, culture, ethnic composition, and organization of healthcare services in Canada, scholars have highlighted the need for Canadian-based studies exploring how language barriers contribute to inefficiencies within the Canadian healthcare system and what strategies can be developed to address the gaps [ 10 , 15 ]. This study explores the impact of language barriers at each point of contact with the healthcare delivery system, from the perspective of immigrants and healthcare providers in a Canadian province that is witnessing a rapid influx of immigrants [ 2 ]. Taking a comprehensive approach, the study examined the overall impacts of language barriers on healthcare access, satisfaction with care received and health outcomes.

The study was set in a mid-size prairie city. An exploratory qualitative research approach guided by the principles of community-based research methods was adopted. Clinicians on the research team experienced many challenges while caring for both immigrants and refugees with language barriers. These clinicians approached community members for their perspective. The study idea was conceived after collective brainstorming with multi-sectoral stakeholders, including: representatives from a non-government settlement agency providing various settlement services to immigrants, family physicians caring for both immigrants and refugees in the city, and health researchers. Each stakeholder represented a specific ethnic-minority group and arrived in Canada as a landed immigrant. Through personal experiences and professional interactions with other immigrants, the stakeholders knew about barriers experienced during healthcare access.

Thereafter, stakeholders developed a research partnership. They collectively decided to document these challenges and leverage the research results to advocate for improved healthcare services. The study aim was to explore the perspectives of immigrants and of healthcare providers. Other groups, such as temporary migrant workers and refugees, have other unique challenges not within the scope of the study. Community partners assisted the research team to finalize the research question and determine methods of participant recruitment. The study was carried out in two parts and approved by the provincial health authority’s research ethics board (REB 14–122 and REB 15–69).

Participants

A purposeful sampling method was used. Community partners assisted with participant recruitment by engaging those seeking services through a settlement agency. All participants recruited were immigrants. The consent form and roles of research participants were shared with all 43 individuals attending English language classes at the settlement agency. Language assistance was provided by interpreters and the English language teachers facilitating the classes. Thirty-seven individuals (28 female and nine male) from 15 different countries signed consent forms. Three participants were travelling, two just began English language classes and one participant was not interested and were excluded. All participants lived in Canada for less than 6 years and are hereafter referred to as “clients.” Please refer to demographic information of clients in Table  1 .

Data collection

The focus group discussion (FGD) questions were developed in consultation with the settlement agency staff and focused on: a) the clients’ perceptions of health and the services needed to stay healthy; b) differences between the healthcare systems in the client’s country of origin and Canada; c) access to healthcare services; d) challenges clients faced when accessing care in Canada; and, e) how clients made decisions about healthcare. Clients received the questions before the FGD to organize their thoughts. Medical students representing specific ethnic groups and speaking an additional language assisted with data collection and interpretation during the FGDs.

Three FGDs were held at the settlement agency and lasted 2 h with breaks for refreshments. Each FGD was attended by 10–15 clients and subgroups of 3–4 clients were coordinated by a facilitator speaking the same language. Clients with language barriers were supported by facilitators speaking their language, other clients with advanced English language proficiency, or language interpreters.

Responses from clients were written down by facilitators and reread to the clients for accuracy. Some clients had written down their thoughts in English using online translators prior to the actual FGD to help them verbalise their thoughts with ease. Clients read out their responses during the FGDs and handed in those written notes after the FGDs. Facilitators also wrote field notes of the salient points emerging from these sessions and their reflections, which informed subsequent FGDs. None of the clients received services from any of the family physicians on the research team during data collection. Complementary child minding, light refreshments and a $20 gift card to a grocery store were provided as incentives to participate.

In part 2, healthcare providers’ perspectives on caring for immigrants and refugees were explored to show a more comprehensive view of the situation. Seventeen healthcare providers and health administrative staff signed the consent form: four family physicians, two family physicians providing obstetrical care, a psychiatrist, a registered nurse, a lab technician, a pharmacist, a nutritionist, a psychiatric social worker, a counsellor, an exercise therapist, an ultrasound technician, an executive director, and a receptionist. They were recruited from a community clinic that predominantly served refugees, immigrants, and other socio-economically disadvantaged populations in the city, other medical clinics in the city, and a hospital.

Healthcare providers serving immigrants and refugees participated in an hour-long, in-depth individual interview focusing on a) health services required to better address the healthcare needs of immigrants and refugees; b) the availability of culturally-responsive healthcare services; and c) the barriers to providing such care. Family physicians on the research team with extensive experience caring for immigrants and refugees assisted with the development of the interview guide and data collection. Interviews were carried out in English and were audio recorded. No compensation was provided.

The FGDs and healthcare provider interviews were transcribed verbatim. Data was analyzed qualitatively using NVivo version 9 following the procedure proposed by Miles, Huberman, and Saldana [ 40 , 41 ]. During preliminary data analysis, two rich transcripts were open coded by a team of researchers. Although the project was carried out to explore barriers to healthcare access for immigrants, language barriers emerged as a distinct theme impacting various aspects of care during data analysis. The results were shared with the settlement agency representatives. A collective decision was made to highlight the impacts of limited English language proficiency on healthcare access, utilization, and outcomes for immigrants in this manuscript. This framework guided the rest of the data analysis. The research team collectively reviewed the completed data analysis report and no new themes emerged at this discussion. The research team collectively agreed that further clarifications were not required from participants. Therefore, follow-up focus groups or interviews were not carried out and no new participants were recruited..

Data was broken into 120 base-level codes. The base-level codes were reviewed a second time, and codes with similar concepts were consolidated into 45 intermediate codes. The intermediate codes were categorized under 11 sub-themes. Title was assigned to each sub-theme to highlight the diverse and pertinent concepts represented by each sub-theme. The sub-themes were then organized under four central themes. Diagrammatic representation shows the relationship between the 11 sub-themes and the four themes and is illustrated in Fig.  1 . Field notes maintained by facilitators were used to cross-reference the themes emerging during data analysis to ensure all pertinent themes were included. The diagram demonstrating the relationship with the subthemes was approved by all team members.

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

Impacts of limited English language proficiency have been summarized under four main themes as follows.

Theme 1: ability to access health information and services

Language proficiency significantly impacted a client’s ability to identify services needed, to secure appointments, and to effectively engage with healthcare providers while seeking care and managing post-appointment care and follow-up. Information about healthcare services is usually provided in English or French. Thus, a client with language barriers lacked adequate information about available services and was unable to access services promptly. Clients with language barriers are less likely to actively seek health and/or mental health services when needed, as is evident from a client’s comment: “ No do not know about mental health services because of the language problem. Can I go to the hospital to access it?” [client]. Another client inquired: “ Do I need appointments for blood tests? ”

The range of healthcare services offered in different countries differs significantly. Lack of knowledge about existing healthcare services in the city created a barrier, which was greatly influenced by clients’ local language proficiency. A healthcare provider in the study commented that,

“We need to make the community or the clients’ population know that this is available for you and this is the process how you get access to this service, the language barrier is a huge barrier for this population and to access like any health care service.”

The way in which healthcare is organized and coordinated varies from country to country, and for newcomers, understanding the services provided within the host country largely depends on their ability to decipher information about them. Those with language limitations might not know how to access various healthcare services. This can lead to misunderstanding between the client and the provider, causing frustrations and unfulfilled expectations for both, as one healthcare provider noted:

“I offer free prescription delivery, but clients didn't come to the door, they didn't understand that the delivery person is delivering it and all they're doing is going to the door, ringing the doorbell expecting them to be let in. On numerous occasions, we were unsuccessful because they [clients] wouldn't open the door, there was no one there or-they did not understand, so, unless someone on the other end speaks English and tells us they're going to be there, we won't deliver now.”

Experience with healthcare delivery in clients’ countries of origin and cultural beliefs about health and what healthcare services should be accessed can interfere with their healthcare access. Language barriers may impede a client’s ability to understand the differences between healthcare organization in Canada and in their country of origin, leading to the underutilization of healthcare services, as one healthcare provider explained:

“If you don't know their language, it becomes difficult to provide care to them. Also, cultural beliefs can interfere with access to care. For example, they [immigrants and refugees with language barrier] do not know how to access an optometrist or dentist. So, I have to give them a lot of information as they have no idea.”

Due to language barriers, clients experienced difficulty following conversations with receptionists, providing proper documentation required for coordinating care, and booking and attending appointments. Clients with language barriers were less likely to seek clarifications when they did not understand instructions or to advocate for their needs. As one client noted, “I don’t speak good English. Therefore, sometimes it is difficult to understand what the receptionist is saying.”

Similarly, a health administrative staff mentioned “I am still waiting for the healthcare number from three clients. They [clients with language barrier] do not understand it is necessary for billing purposes ”.

The degree to which clients with limited language proficiency are able to access the healthcare services they need largely depends on their ability to understand information that is written in English and to understand how the healthcare system is organized.

Theme 2: ability to develop a therapeutic alliance with healthcare providers

English language proficiency significantly affected the therapeutic relationship between patients and healthcare providers. Clients with language barriers were unable to explain their health conditions adequately, as one client noted:

“Without proficiency in English, it is difficult talking to the health care provider. It's a problem to describe what you're feeling. It will be easier as a newcomer if they have a family doctor who speaks the same language. Like for children with pain, it is difficult for them to say what they [children] want or to make them [children] understand .”

Clients reported experiencing difficulty asking questions about their health and understanding treatment instructions. One client mentioned that,

“Sometimes, the doctors describe the illness in a way that I don’t understand what the doctors say. Sometimes this makes it very hard to go to the doctors because of the language problems.”

Healthcare providers were often concerned about not getting adequate information about health concerns from patients with language barriers. They experienced difficulties during physical examinations or when providing treatment instructions, which can have adverse outcomes, as one healthcare provider explained:

“Say I am treating an ear infection. I have told the clients many times that the medication is to be administered by mouth, but they thought it was to be installed in the ears. So, I have a couple of disastrous cases where I have prescribed medication where they don’t realize it is given by mouth. I think also, when they don’t understand, they feel uncomfortable to ask for clarification. They get very embarrassed and they get very frustrated.”

Similarly, clients with English language barriers also mentioned difficulty understanding medication regime as a client mentioned.

“I had problems with the iron levels, the doctors prescribed iron pills. I asked the doctors how many to take, but he did not explain it properly. He first said that I should take one pill a day, then when I ask if that will be enough, he said I can take 2 to 3 pills. How can he advise me like that without explaining it properly?”

Theme 3: challenges with engaging language interpreters

Language interpreters are not available at all clinics and families often bring ad hoc interpreters to the appointments or use volunteers working within the healthcare system. Often, these ad hoc interpreters lack adequate skills and training to carry out medical translation, which creates additional challenges. Healthcare providers may not feel confident that instructions are being translated verbatim. They also noted that often they received a summarized or concise version of what the clients narrated and wondered whether valuable contextual information was lost during translation. This can be frustrating for the healthcare providers and interfere with the development of the therapeutic alliance, as a healthcare provider pointed out:

“Some of the barriers I've experienced, those mainly had to do with communication and interpreters. I guess sometimes I wonder with the translation, what is being said to the patient. because they have quite a long discussion, and then when I ask the interpreter what was said … oh, they have no questions. *laughs* so I'm not sure what the conversation was, so that can be a little bit, um, frustrating.”

Further, some interpreters might provide a cultural and/or religious interpretation of strategies that might not align with Western medical care, as this healthcare provider explained:

“There are times when the clients will bring in their interpreters that I don't feel that my teaching and my advice is being given to them appropriately or word for word. I find that the personal interpreters they bring in will contraindicate and conflict with what I am telling the client because they will say "no that's not how we do things" instead of telling the client what I as a practitioner would like them to do”.

Sometimes, ad hoc interpreters are less helpful in assisting with client-provider communication and they may become an impediment to the therapeutic alliance, as a healthcare provider noted:

“Sometimes working with an interpreter is difficult because you don't always know whether the translator translates exactly what you're trying to come across or explain.”

Some clients were also concerned that their messages were not communicated properly to the healthcare providers during translation as a client mentioned:

“ I cannot speak English so I cannot go by myself to the doctor … … Before I had to wait for my husband he works, and say everything fast as he had to go back to work soon, I could not say everything I wanted, to the doctors, but now my son comes with me so it is better but I have to remind him always to say everything I said, to the doctor as he is still young and may forget .”

A medical interpreter’s presence can create privacy and confidentiality issues, especially for clients with mental health issues. Interpreters assisting clients with mental illness require training to create culturally safe interactions, lest the interaction become more injurious to the clients than the illness itself. The excerpt below from a healthcare provider is an excellent example of culturally unsafe medical translation.

“I had this case where the interpreter was not trained in mental health, and they found the conversation to be funny, so it was an elderly Asian lady who had delusions and hallucinations—well, we had a hard time with that. The interpreter was laughing.”

Some clients were uncomfortable receiving language assistance from family or individuals of the same community. As is mentioned by a women client:

“ I need lady doctor or lady speaking my language. I need medicine to stop baby [contraception] where can I get it. I cannot talk about this with my doctors when others [family members who help with translation] are there with me and I am waiting for 3 months now.”

Moreover, healthcare providers were sometimes concerned about the quality of the translation services provided to their clients. Healthcare providers observed that some interpreters struggled to explain instructions adequately during sample collection and diagnostics tests, leading to delays in the treatment process and linkage to treatment. One healthcare provider conveyed the issues with inadequate medical translation:

“I requested that the client present with a stool sample in the container provided. A couple of times, some clients showed up with urine in there rather than stool. This is after numerous explanations with an interpreter present.”

Another healthcare provider mentioned that:

“Giving simple instructions such as the need for a full bladder before ultrasound, many don’t understand what bladder is. Last week I tried to conduct spirometry on a patient even with the presence of an interpreter and I was not successful. He just didn't understand. I guess he [interpreter] did not translate accurately.”

Effective communication between healthcare providers and clients is vital for providing safe and quality healthcare.

Theme 4: impacts of language barriers on health outcome and strategies addressing gaps

Clients with language barriers often manage care on their own and due to lack of effective communication they are often dissatisfied with care received. Clients felt as though it was not worth seeking care when there was no means of addressing their language limitations, as one client noted:

“This country has so much resources and sometimes I feel the resources are not put to good use . What is the point of seeing a doctor if I do not feel satisfied? First, you must make appointments, manage everything at home to go for that appointment, and then still wait when you reach there, and then the doctors hardly spend time with you.”

In many countries healthcare is accessed on a need to basis and individuals might not have understanding about preventative health. Emphasis is given on preventative medicine in Canada, but providing health education can be challenging due to language barriers as a healthcare provider pointed out:

“If they don’t understand the preventative or the treatment plan but instead of perhaps doing some preventative stuff, they want to jump right to the surgery or jump right to the medication. Like PAP smears and mammograms, there is a lack of education in those countries where they come from. There are no concepts of preventative health care there. We tried to offer an information session with interpreters it really slowed down the meeting; everyone had to wait for the interpreter to interpret our directions and if we didn’t immediately have them interpret the participants were having a hard time following the conversation”

Healthcare providers were apprehensive about the dangers that clients with language barriers might face away from healthcare setting, as was explained by this healthcare provider:

“First of all, they [clients] might not understand what I'm telling them when I'm asking them to administer insulin themselves and increasing their doses based on their numbers. A lot of times they’re very confused on that fact and the translation, something is getting lost in the translation. Any misunderstanding can put them in a very dangerous situation if they give themselves too much insulin.”

Language ability can interfere with chronic disease management, which requires continual monitoring through regular clinic appointments. Even with medical translation, some clients may not comprehend the steps in the treatment plan that they are required to follow to manage chronic conditions effectively. Without additional supports available after medical appointments, these patients struggle to set up follow-up appointments, refill prescriptions, and adhere to medical instructions. In the absence of supports, treatment adherence might be poor. A healthcare provider describes what happens when clients don’t receive post-appointment follow-up or support:

“A lot of them [clients] have chronic conditions such as hypertension and don't come for a routine check-up. You'll see them and start them on medication and try to emphasize that this is long term treatment, and they will need to come back in a month for a check-up. You'll see that they've shown up a year later, and yet they were prescribed medications to last them for one month only and didn't renew them even though they had renewals. They will show up a year later with a headache or something, and their blood pressure is way out of control. I see that a lot.”

Clients mentioned adopting few strategies to address language barriers. Women clients often preferred same gender interpreters for women health issues and they depended on family and friend circles for assistance as a client mentioned: “ I have a very good friend who took holiday from work to come with me, I had to talk to the doctor about women problem .” Clients also consulted friends or family to find relevant healthcare services near them. A client mentioned: “I will ask my sister for healthcare for my family she and her family help us when we need information. I can also find out using the internet.” Clients might also seek information about healthcare services and ways to access it from community organizations providing settlement services as a client mentioned: “ I ask my English teacher when I need information about healthcare services they can help me. ”

Some clients pointed out that finding providers from their ethnic background would be helpful. Many clients take it upon themselves to seek care from these providers and may delay healthcare access, as this participant mentioned: “I am waiting to find a doctor who speak my language and can understand my culture.” Matching clients with providers from the same linguistic and ethnic background is useful but challenging. It may be more feasible in larger cities with larger and established ethnic groups. A client who received care from a provider from the same ethnic background mentioned a positive experience, as is evident from this comment:

“My doctor is from my country and he was able to explain to me why I need the surgery (hysterectomy). I was scared and I did not want to do it, but my husband and my doctor helped me understand that it was needed and if I did not get it done I will get very sick, I did it and I am alright now.”

Alternatively, healthcare providers who are culturally attuned to the challenges that clients with language barriers face are often empathetic and accommodative and ensure that clients receive the required care. One healthcare provider noted:

“They experience barriers accessing health care due to language limitations. Some clients may have challenges with conceptualizing what constitutes good health. This is partly informed by the fact that most of them may have experienced marginalization for so long. Therefore, [clients] might not have the right access to information or ask the right question. I try to talk to them at their level of understanding.”

Specialized clinics providing services to immigrants and refugees might have trained interpreters; however, their time might be limited, and they might not be available for healthcare services outside the clinics. One healthcare provider mentioned:

“We are lucky to have interpreters in our clinic but their time is limited and most of their time is allocated for in-person appointments in the clinics and they might not be available to provide support for other program such as health promotion.”

To achieve a positive treatment outcomes among immigrants with language barriers, effective coordination of care, good patient-provider communication and assistance with follow-up into the community post appointment are required. Lack of these ancillary services discourages individuals from accessing healthcare services. This is evident from a client’s comments:

“ I cannot speak English well and so cannot explain what I need I got so frustrated with the doctors did not go to see one in one whole year but that came to harm me. I now have pain in my ankle which is growing but what is the use of telling the doctors I cannot explain properly and they will not understand and it will not help .”

Individuals might delay access to healthcare which increases patients’ vulnerability to adverse health outcomes.

This study includes the perspectives of immigrants in a Canadian city and healthcare providers serving them. Consistent with the literature, both patients and providers unanimously agreed that limited English language proficiency significantly impacts access to care, quality of care received, and health outcomes for immigrants throughout the continuum of care [3, 10, 15–17, 26–29, 31, 33]. This study examined the impacts of language barriers at all points of contact with the healthcare delivery system. The study highlights that the impacts of language barriers are evident long before an individual meets with a healthcare provider and persist long after an individual has received a treatment or intervention. The cumulative impact of this is delayed access to timely healthcare, suboptimal care, increased risk of adverse events, dissatisfaction with care received and poor health outcomes. The study emphasizes that healthcare delivery in Canada cannot be improved by providing language interpreters during medical consultation alone. A more comprehensive approach is required that includes, developing best practice guidelines for providers, training for interpreters and policy change to address the impacts of language barriers on healthcare delivery, utilization and health outcomes in Canada. This study highlights four ways in which limited English language proficiency can interfere with immigrants’ healthcare access and health outcomes.

As observed by Floyd and Sakellariou [ 29 ], clients in our study were unaware of the available healthcare services, lacked knowledge about ways to navigate the healthcare system, and were unable to advocate for needed services [ 25 ]. Language barriers impacted clients’ engagement with prevention, health promotion, and allied health services, which can create the misperception that they are disengaged in care. Other studies have also identified that language barriers influence access to and use of preventative medicine and screening [ 30 , 42 , 43 , 44 ]. Language barriers interfere with the ability to find information about healthcare services and eligibility. This leads to fragmented, suboptimal care and/or delayed linkage with appropriate care [ 4 , 30 ].

Clients and providers consistently mentioned that language barriers interfered with the development of therapeutic relationships. As observed in other studies, language barriers impeded effective health information sharing and communication between patients and providers, thereby undermining trust [ 16 , 26 , 27 , 28 , 29 , 30 ]. Similar to what De Moissac and Bowen [ 38 ] observed, the clients in this study also mentioned difficulty describing pain and other symptoms to their healthcare providers, which can interfere with accurate diagnoses [ 25 , 32 , 45 ]. Clients with limited language abilities are at risk of delaying treatment [ 4 , 38 ], misdiagnosis, or mismanagement of their conditions [ 38 , 46 ]. Like those reported in other studies, our results also demonstrated specific instances where language barriers increased the chances of medical errors and harms due to patient’s inability to understand and/or follow treatment plans [ 15 , 17 , 25 , 38 ].

Consistent with the findings of systematic reviews [ 16 , 47 ], the providers in this study indicated that interpreters were helpful. As observed in other studies [ 16 , 29 , 30 ], clients in this study also emphasized the need for bilingual healthcare providers. Community health navigators can help improve access to primary and preventative healthcare services while acting as cultural brokers and language interpreters [ 48 ]. Molina and Kasper called for language-concordant care, as it has been shown to provide safe and high-quality care [ 49 ].

However, this study adds to the discussion in the literature about the challenges that arise when ad hoc interpreters are involved [ 50 ]. Consistent with the literature, the healthcare providers in this study indicated that interpreters’ roles are often unstructured. Instead of verbatim translating, an interpreter might summarize information or provide their own interpretation of what the patient and/or the provider said, leading to suboptimal conversation and care [ 3 , 42 ]. Interpreters are also unsure about their role in medical translation [ 18 ]. Although healthcare providers wanted verbatim translation in our study, other studies observed that healthcare providers might expect interpreters to also act as cultural brokers or care coordinators [ 3 , 18 , 42 ]. Our results provided evidence of situations when some medical interpreters could not provide culturally safe translation support, especially when sensitive and taboo topics were involved [ 3 ]. Providers might not feel comfortable or prepared to care for immigrants with language barriers [ 25 ]. Language barriers may slow down conversations and additional follow-ups are required thereby increasing stress and workload for providers [ 27 , 42 , 47 , 51 ].

In this study, clients and providers both indicated that multiple sessions might be required to communicate instructions for treatment and sample collection [ 42 ]. As observed by Ali and Watson [ 17 ] in the United Kingdom, the healthcare providers in this study also reported that interpreters might not be able to translate treatment plans, instructions for sample collection, or instructions for screenings because of their lack of medical knowledge. As discussed in the literature, the healthcare providers in this study also highlighted issues with privacy and confidentiality when ad hoc interpreters, family members, or individuals from the same ethnic groups are involved [ 3 , 43 , 50 , 52 ]. Studies indicate that clients with limited English language proficiency prefer professional gender-concordant interpreters over family members [ 53 ]. Although studies show that without medical interpreters the quality of care is compromised for clients with language barriers, interpretation errors often occur when ad hoc interpreters are used [ 10 , 16 , 25 , 26 , 50 , 52 , 54 ]. Professional interpreters raise the quality of clinical care compared to ad hoc interpreters [ 50 , 54 ].

Finally, the present study highlighted how English language proficiency creates an additional layer of barriers to healthcare access, utilization, and patient satisfaction [ 3 ]. Inability to communicate effectively with healthcare providers creates dissatisfaction for patients because their needs were not communicated and they are not getting the services needed [ 16 , 27 ]. Moreover, language barriers limit a healthcare provider’s ability to provide care in a timely, safe manner; subsequently, the client’s needs are unmet [ 4 , 16 , 17 , 27 , 32 ].

Language barriers also create dissatisfaction for healthcare providers as they are unable to engage patients in health promotion and preventative programs [ 42 , 44 ], offer additional supports like home delivery for medications, or support them with treatment adherence. Language barriers might cause embarrassment, disempower patients, and undermine patients’ confidence [ 25 , 28 , 30 ]. Floyd & Sakellariou [ 29 ] observed that refugee women with language barriers are likely to experience racism, and might not be engaged in healthcare decision making. Additionally, cultural belief and experience with the healthcare delivery system in the country of origin influence the type of healthcare services that will be accessed and expectation from healthcare providers [ 3 , 28 , 30 ]. Due to a lack of culturally appropriate care, access to healthcare services can be delayed or underutilized [ 12 , 24 , 30 , 31 ].

Floyd and Sakellariou [ 29 ] observed that the Canadian healthcare system is organized on the assumption that service seekers can read and understand English, which marginalizes immigrants, refugees, and others with lower literacy and limited English language proficiency.

Parsons, Baker, Smith-Gorvie, and Hudak [ 55 ] mention that it is unclear who is responsible for ensuring that communication between providers and patient is adequate. Guidelines are required for healthcare providers outlining when interpreters should be involved. Papic et al. [ 47 ] highlighted the need for clear directives for determining who is responsible for arranging interpreters and finding ways to enhance the involvement of professional interpreters and multicultural clinics where available.

As a country that promotes and celebrates multiculturalism, the Canadian Charter of Rights and Freedoms (1982) guarantees equal rights, such that Canadians are to be treated with the same respect, dignity, and consideration regardless of race, nationality, ethnicity, color, religion, sex, or age [ 56 ]. Healthcare access needs to be regarded as a basic human right under the Charter and not be contingent on language proficiency. Although most immigrants arrive with better health status than the local population, largely attributed to initial health selectivity and the Canadian immigration policy, their health status tends to decline over time to levels worse than native-born citizens [ 3 , 57 , 58 , 59 , 60 ]. This deterioration has been partly attributed to discrimination and unfair treatment that immigrants experience in the healthcare system [ 60 ].

Aery [ 61 ] proposed that a health equity perspective is required to address the socio-cultural barriers faced by vulnerable populations, including immigrants and refugees. Ali and Waston [ 17 ] proposed that addressing language barriers is an essential step towards providing culturally responsive and client-centered care. The importance of enabling patients to actively participate in their healthcare has received extensive policy attention [ 62 ]. Giving patients an active role in their healthcare empowers them and improves services and health outcomes [ 63 ]. Involving patients in shared decision making is emphasised in Saskatchewan, Canada [ 64 ]. Against this backdrop, patients, providers, and interpreters in Canada need to be engaged to understand the multi-layer barriers at the individual, community, and health-system levels and address those needs [ 42 ].

Limitation of the study

A small number of clients from each ethnic group was recruited; therefore, results might not reflect the experience of the respective ethnic groups as a whole. With a larger number of female clients recruited in the study, the views are more reflective of female than male patients with language barriers. A small number of healthcare providers were recruited from each discipline. Further research is required to capture discipline-specific challenges encountered by providers caring for patients with language barriers. The study did not include migrant workers and refugees and additional research is required to highlight specific challenges experienced by specific groups.

Implications for practice

The results of the study are relevant for any country accepting immigrants from linguistically diverse countries. Through professional courses, continued education, and development of best practice guidelines healthcare providers in Canada should be equipped with adequate knowledge and skills to care for patients with language barriers [ 49 ].

Interpreters in Canada should have clear instructions about whether only verbatim translation is required or they need to serve as cultural brokers and/or support clients with coordination of care. A national strategy should be developed in Canada to train, support, and supervise interpreters adequately to ensure that they deliver safe, and impactful services [ 35 ].

Availability of data and materials

All data generated or analysed during this study are available from the corresponding author on reasonable request.

International Organization for Migration (IOM). World Migration Report 2020, UN, New York; 2019. p. 492. [cited 2021 Feb 26] Available from https://doi.org/10.18356/b1710e30-en .

Statistic Canada. Immigration and ethnocultural diversity: key results from the 2016 census [internet]. Ottawa: Statistics Canada; 2017. p. 8. [cited 2021 Feb 26]. Available from: https://www150.statcan.gc.ca/n1/en/daily-quotidien/171025/dq171025b-eng.pdf?st=WbM3u6Dy .

Ahmed S, Shommu NS, Rumana N, Barron GR, Wicklum S, Turin TC. Barriers to access of primary healthcare by immigrant populations in Canada: a literature review. J Immigr Minor Health. 2016;18(6):1522–40. https://doi.org/10.1007/s10903-015-0276-z .

Article   PubMed   Google Scholar  

Marshall EG, Wong ST, Haggerty JL, Levesque JF. Perceptions of unmet healthcare needs: what do Punjabi and Chinese-speaking immigrants think? A qualitative study. BMC Health Serv Res. 2010;10(1):1–8.

Article   Google Scholar  

Refugee I, Canada C. 2020 Annual report to parliament on immigration [internet]: Immigration, Refugee and citizenship Canada; 2020. [cited 2021 march 14]. 41p. Cat. No. Ci1E-PDF. Available from: https://www.canada.ca/content/dam/ircc/migration/ircc/english/pdf/pub/annual-report-2020-en.pdf

Boyd M, Cao X. Immigrant language proficiency, earnings, and language policies. Canadian Studies in Population [ARCHIVES]. 2009;36(1–2):63–86. https://doi.org/10.25336/P6NP62 .

Dustmann C, Fabbri F. Language proficiency and labour market performance of immigrants in the UK. Econ J. 2003;113(489):695–717.

Sakamoto I, Ku J, Wei Y. The deep plunge: Luocha and the experiences of earlier skilled immigrants from mainland China in Toronto. Qual Soc Work. 2009;8(4):427–47. https://doi.org/10.1177/1473325009346518 .

Ng E, Pottie K, Spitzer D. Official language proficiency and self-reported health among immigrants to Canada. Health Rep. 2011;22(4):15-23.

Laher N, Sultana A, Aery A, Kumar N. Access to language interpretation services and its impact on clinical and patients outcomes: a scoping review. Toronto: Wellesley Institute: Advancing Urban Health; 2018. p. 1–78.

Google Scholar  

Delara M. Social determinants of immigrant women’s mental health. Adv Public Health. 2016;2016:1–11. https://doi.org/10.1155/2016/9730162 .

Kirmayer LJ, Narasiah L, Munoz M, Rashid M, Ryder AG, Guzder J, et al. Common mental health problems in immigrants and refugees: general approach in primary care. CMAJ. 2011;183(12):E959–67. https://doi.org/10.1503/cmaj.090292 .

Article   PubMed   PubMed Central   Google Scholar  

Thomson EF, Andrea M, Noack AM, George U. Health Decline Among Recent Immigrants to Canada: Findings From a Nationally-representative Longitudinal Survey. Can J Public Health. 2011;102(4):273–80.

Luiking ML, Heckemann B, Ali P, Dekker-van Doorn C, Ghosh S, Kydd A, et al. Migrants’ healthcare experience: a meta-ethnography review of the literature. J Nurs Scholarsh. 2019;51(1):58–67. https://doi.org/10.1111/jnu.12442 .

Bowen S. The impact of language barriers on patient safety and quality of care. Société Santé Français. 2015. p. 53.

Joshi C, Russell G, Cheng IH, Kay M, Pottie K, Alston M, et al. A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination. Int J Equity Health. 2013;12(1):1–4. https://doi.org/10.1186/1475-9276-12-88 .

Ali PA, Watson R. Language barriers and their impact on provision of care to patients with limited English proficiency: Nurses' perspectives. J Clin Nurs. 2018;27(5–6):e1152–60. https://doi.org/10.1111/jocn.14204 .

Messias DK, McDowell L, Estrada RD. Language interpreting as social justice work: perspectives of formal and informal healthcare interpreters. Adv Nurs Sci. 2009;32(2):128–43. https://doi.org/10.1097/ANS.0b013e3181a3af97 .

Poureslami I, Rootman I, Doyle-Waters MM, Nimmon L, FitzGerald JM. Health literacy, language, and ethnicity-related factors in newcomer asthma patients to Canada: a qualitative study. J Immigr Minor Health. 2011;13(2):315–22. https://doi.org/10.1007/s10903-010-9405-x .

Sumin N, Andrew R, Laurence K. Towards a culturally responsive model of mental health literacy: facilitating help-seeking among east Asian immigrants to North America. Am J Community Psychol. 2016;58(1/2):211–22.

Lee TY, Landy CK, Wahoush O, Khanlou N, Liu YC, Li CC. A descriptive phenomenology study of newcomers’ experience of maternity care services: Chinese women’s perspectives. BMC Health Serv Res. 2014;14(1):1–9.

Anand AS, Cochrane R. The mental health status of south Asian women in Britain: a review of the UK literature. Psychol Dev Soc. 2005;17(2):195–214. https://doi.org/10.1177/097133360501700207 .

Chen AW. Immigrant access to mental health services: conceptual and research issues. Canadian Issues. 2010. p. 51-54. https://multiculturalmentalhealth.ca/wp-content/uploads/2019/07/Immigrant_mental_health_10aug10.pdf .

Fang L. Mental health service utilization by Chinese immigrants: barriers and opportunities. Canadian Issues. 2010. p. 70-74. https://multiculturalmentalhealth.ca/wp-content/uploads/2019/07/Immigrant_mental_health_10aug10.pdf .

Goenka PK. Lost in translation: impact of language barriers on children's healthcare. Curr Opin Pediatr. 2016;28(5):659–66. https://doi.org/10.1097/MOP.0000000000000404 .

Ahmed S, Lee S, Shommu N, Rumana N, Turin T. Experiences of communication barriers between physicians and immigrant patients: a systematic review and thematic synthesis. Patient Experience J. 2017;4(1):122–4. https://doi.org/10.35680/2372-0247.1181 .

Al Shamsi H, Almutairi AG, Al Mashrafi S, Al KT. Implications of language barriers for healthcare: a systematic review. Oman Med J. 2020;35(2):e122. https://doi.org/10.5001/omj.2020.40 .

Dastjerdi M, Olson K, Ogilvie L. A study of Iranian immigrants’ experiences of accessing Canadian health care services: a grounded theory. Int J Equity Health. 2012;11:55. https://doi.org/10.1186/1475-9276-11-55 .

Floyd A, Sakellariou D. Healthcare access for refugee women with limited literacy: layers of disadvantage. Int J Equity Health. 2017;16(1):1–0.

George P, Terrion JL, Ahmed R. Reproductive health behaviour of Muslim immigrant women in Canada. Int J Migration Health Soc Care. 2014;10(2):88-101.  https://doi.org/10.1108/IJMHSC-09-2013-0032 .

Higginbottom G, Safipour J. Access to primary health care by new and established immigrants in Canada. J Fam Med Commun Health. 2015;2(5):1–7.

van Rosse F, de Bruijne M, Suurmond J, Essink-Bot ML, Wagner C. Language barriers and patient safety risks in hospital care. A mixed methods study. Int J Nurs Stud. 2016;54:45–53. https://doi.org/10.1016/j.ijnurstu.2015.03.012 .

Gulati S, Watt L, Shaw N, Sung L, Poureslami IM, Klaassen R, et al. Communication and language challenges experienced by Chinese and south Asian immigrant parents of children with cancer in Canada: implications for health services delivery. Pediatr Blood Cancer. 2012;58(4):572–8. https://doi.org/10.1002/pbc.23054 .

Aery A, Kumar N, Laher N, Sultana A. (2017). Interpreting consent – a rights based approach to language accessibility in Ontario’s health care system: Wellesley institute; 2017. p. 1–14. Retrieved from: http://www.wellesleyinstitute.com/publications/interpreting-consent-a-rights-based-approach-to-language-accessibility-in-ontarios-health-care-system/

Bowen S. Language barriers in access to health care. Ottawa: Health Canada; 2001.

Tam V, Buchana F, Lurette C. How do we ensure that patients receive care in their own languages? [internet]. Healthydebate. 2018; [updated 2018 Dec13; cited 2021 April26]. Available from https://healthydebate.ca/2018/12/topic/language-interpretation-in-health-care/ .

Kumar N, Laher N, Sultana A, Aery A. The right to language accessibility in Ontario’s Healthcare system. [internet]: Wellesley Institute; 2017. [cited 2021 April24]. Available from https://www.wellesleyinstitute.com/health/the-right-to-language-accessibility-in-ontarios-health-care-system/

De Moissac D, Bowen S. Impact of language barriers on quality of care and patient safety for official language minority Francophones in Canada. J Patient Experience. 2019;6(1):24–32. https://doi.org/10.1177/2374373518769008 .

Census. Linguistic integration of immigrants and official language populations in Canada. Statistic Canada. 2017. https://www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/2016017/98-200-x2016017-eng.cfm

Miles MB, Huberman AM, Saldaña J. Qualitative data analysis: a methods sourcebook: Sage publications; 2018.

QSR International Pty Ltd. Powerful research, simplified [Internet]. Doncaster: QSR International Pty Ltd; [cited 2021 Feb 26]. Available from: https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/about/nvivo .

Bruce KH, Schwei RJ, Park LS, Jacobs EA. Barriers and facilitators to preventive cancer screening in limited English proficient (LEP) patients: physicians’ perspectives. Commun Med. 2014;11(3):235. https://doi.org/10.1558/cam.v11i3.24051 .

Marques P, Nunes M, da Luz AM, Heleno B, Dias S. Factors associated with cervical cancer screening participation among migrant women in Europe: a scoping review. Int J Equity Health. 2020;19(1):1–5.

Ferdous M, Lee S, Goopy S, Yang H, Rumana N, Abedin T, et al. Barriers to cervical cancer screening faced by immigrant women in Canada: a systematic scoping review. BMC Womens Health. 2018;18(1):1–3. https://doi.org/10.1186/2Fs12905-018-0654-5 .

Bischoff A, Bovier PA, Isah R, Françoise G, Ariel E, Louis L. Language barriers between nurses and asylum seekers: their impact on symptom reporting and referral. Soc Sci Med. 2003;57(3):503–12. https://doi.org/10.1016/s0277-9536(02)00376-3 .

Reitmanova S, Gustafson DL. “They can’t understand it”: maternity health and care needs of immigrant Muslim women in St. John’s, Newfoundland. Matern Child Health J. 2008;12(1):101–11. https://doi.org/10.1007/s10995-007-0213-4 .

Papic O, Malak Z, Rosenberg E. Survey of family physicians’ perspectives on management of immigrant patients: attitudes, barriers, strategies, and training needs. Patient Educ Couns. 2012;86(2):205–9. https://doi.org/10.1016/j.pec.2011.05.015 .

Shommu NS, Ahmed S, Rumana N, Barron GR, McBrien KA, Turin TC. What is the scope of improving immigrant and ethnic minority healthcare using community navigators: a systematic scoping review. Int J Equity Health. 2016;15(1):1–2. https://doi.org/10.1186/s12939-016-0298-8 .

Molina RL, Kasper J. The power of language-concordant care: a call to action for medical schools. BMC Med Educ. 2019;19(1):1–5.

Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62(3):255–99. https://doi.org/10.1177/1077558705275416 .

Gerchow L, Burka LR, Miner S, Squires A. Language barriers between nurses and patients: a scoping review. Patient Educ Couns. 2021;104(3):534-53. https://doi.org/10.1016/j.pec.2020.09.017 .

Squires A. Evidence-based approaches to breaking down language barriers. Peer Rev J Clin Excellence. 2017;47(9):34–40.

Ngo-Metzger Q, Massagli MP, Clarridge BR, Manocchia M, Davis RB, Iezzoni LI, et al. Linguistic and cultural barriers to care. J Gen Intern Med. 2003 Jan;18(1):44–52. https://doi.org/10.1046/j.1525-1497.2003.20205.x .

Karliner LS, Jacobs EA, Chen AH, Mutha S. Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727–54. https://doi.org/10.1111/j.1475.6773.2006.00629.x .

Parsons JA, Baker NA, Smith-Gorvie T, Hudak PL. To ‘get by’or ‘get help’? A qualitative study of physicians’ challenges and dilemmas when patients have limited English proficiency. BMJ Open. 2014;4:e004613.  https://doi.org/10.1136/bmjopen-2013-004613 .

Department of Justice Canada. The rights and freedoms the Charter protects [Internet]. Ottawa: Department of Justice Canada; 2018. [cited 2021 Feb 26]. Available from: https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/rfcp-cdlp.html

Jass G, Massey DS. Immigrant health: selectivity and acculturation. IFS Working Papers; 2004.

Riosmena F, Kuhn R, Jochem WC. Explaining the immigrant health advantage: self-selection and protection in health-related factors among five major national-origin immigrant groups in the United States. Demography. 2017;54(1):175–200. https://doi.org/10.1007/s13524-016-0542-2 .

Vang ZM, Sigouin J, Flenon A, Gagnon A. Are immigrants healthier than native-born Canadians? A systematic review of the healthy immigrant effect in Canada. Ethn Health. 2017;22(3):209–41. https://doi.org/10.1080/13557858.2016.1246518 .

De Maio FG, Kemp E. The deterioration of health status among immigrants to Canada. Global Public Health. 2010;5(5):462–78. https://doi.org/10.1080/17441690902942480 .

Aery A. Innovations to champion access to primary care for immigrants and refugees: Wellesley Institute: Advancing Urban Health; 2017. p. 1–14.

Staniszewska S. Patient and public involvement in health services and health research: a brief overview of evidence, policy and activity. J Res Nurs. 2009;14(4):295–8. https://doi.org/10.1177/1744987109106811 .

Vahdat S, Hamzehgardeshi L, Hessam S, Hamzehgardeshi Z. Patient involvement in health care decision making: a review. Iran Red Crescent Med J. 2014;16(1):e12454. https://doi.org/10.5812/ircmj.12454 .

Saskatchewan Health Authority. Primary healthcare for patients. [internet]. Saskatchewan Health Authority [cited 2021 April26]. Available from https://www.saskatchewan.ca/residents/health/accessing-health-care-services/primary-health-care/patients .

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Acknowledgements

We greatly appreciate the support received from the Executive Director of Regina Immigrant Women Center Mrs. Neelu Sachdev and her staff members during the project. We would especially like to thank the teachers facilitating the English language classes, for helping with participant recruitment, data collection, translation and data interpretation. We acknowledge the contributions of Cheghaf Madrati, Sarah Green Wood, Tooba Zahid, Fatima Ahmed and Tannys Bozdech undergraduate medical students who provided language support and assisted with writing the response during the focus group discussion. We also want to thank psychiatry resident Samra Sahlu for assistance with the healthcare provider interviews. Saskatchewan Health Authority and Department of Academic Family Medicine (Regina Campus) University of Saskatchewan provided in-kind support for the project.

This project did not receive any financial support.

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Contributions

Mamata Pandey: She developed the research plan, carried out stake holder consultation, prepared ethics application, collected data, analyzed data, prepared the first draft of the manuscript. Geoffrey Maina: Assisted with finalizing methodology, data analysis, writing methodology, data analysis, results and implication section of the manuscript, extensively review and revised the manuscript. Jonathan Amoyaw: Assisted with literature review, prepared the discussion, limitation and conclusion, reviewed and edited the manuscript. Yiyan Li: Assisted with introduction, literature review, figures and tables and final editing of manuscripts. Rejina Kamrul: Helped with ethics application, carried out consultation with community partners, development of focus group and health care provider interview guides, data collection and analysis and reviewed the final draft of the manuscripts. Clara Rocha Michaels: Assisted with consultation with stakeholders, reviewed ethics application, development of healthcare provider interview guides, data collection, data analysis and reviewed the final draft of the manuscripts. Razawa Maroof: Assisted with ethics application for part 2 of the study, assisted in the development of the interview questions for healthcare providers, carried out interviews with healthcare providers, reviewed the data analysis and final draft of the manuscript. The author(s) read and approved the final manuscript.

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Pandey, M., Maina, R.G., Amoyaw, J. et al. Impacts of English language proficiency on healthcare access, use, and outcomes among immigrants: a qualitative study. BMC Health Serv Res 21 , 741 (2021). https://doi.org/10.1186/s12913-021-06750-4

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Title: knowledge-grounded adaptation strategy for vision-language models: building unique case-set for screening mammograms for residents training.

Abstract: A visual-language model (VLM) pre-trained on natural images and text pairs poses a significant barrier when applied to medical contexts due to domain shift. Yet, adapting or fine-tuning these VLMs for medical use presents considerable hurdles, including domain misalignment, limited access to extensive datasets, and high-class imbalances. Hence, there is a pressing need for strategies to effectively adapt these VLMs to the medical domain, as such adaptations would prove immensely valuable in healthcare applications. In this study, we propose a framework designed to adeptly tailor VLMs to the medical domain, employing selective sampling and hard-negative mining techniques for enhanced performance in retrieval tasks. We validate the efficacy of our proposed approach by implementing it across two distinct VLMs: the in-domain VLM (MedCLIP) and out-of-domain VLMs (ALBEF). We assess the performance of these models both in their original off-the-shelf state and after undergoing our proposed training strategies, using two extensive datasets containing mammograms and their corresponding reports. Our evaluation spans zero-shot, few-shot, and supervised scenarios. Through our approach, we observe a notable enhancement in Recall@K performance for the image-text retrieval task.

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Interviews with home and community-based services users and providers shed light on systemic barriers to the delivery of person-centered services

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Recipients and providers of home and community-based services (HCBS) say that better compensation and training for direct service providers would improve the delivery of person-centered HCBS. The findings are based on interviews with HCBS users and providers focusing on systems-level challenges that hinder the delivery of person-centered HCBS. Their findings are reported in Disability and Health Journal .

HCBS supports people with disabilities in living the lives they want to lead in the community rather than in institutional settings. HCBS can include things like help with shopping, household chores, personal grooming and managing appointments. Taking a ‘person-centered’ approach to HCBS means that people who use HCBS have choice and control over the services they receive and that their needs and preferences inform services received.

In 2014, the Center for Medicaid and Medicare Services issued the Final Settings Rule, which required states to ensure that HCBS are person-centered and meet standards for integration, access to community life, choice, autonomy, and other important consumer protections. Despite widespread adoption of person-centered services, systemic barriers influence service users’ and professionals' experiences in receiving and delivering person-centered services.

To identify barriers to delivering person-centered HCBS, researchers in the Center for Rehabilitation Outcomes Research at Shirley Ryan AbilityLab interviewed 20 Medicaid-funded HCBS users 18 years old or older and 22 HCBS professionals including state waiver personnel, managers and direct service professionals about their experiences receiving and providing person-centered services. 

The most-commonly cited workforce challenges mentioned by participants were the shortage of direct support professionals and the need for more opportunities for practical training on delivering person-centered planning. 

“Participants also spoke about things like resource constraints, staff shortages, and confusing documentation procedures as barriers to HCBS users’ getting their basic needs met and being able to truly exercise choice and control over their lives,” Niveda Tennety, Senior Project Coordinator in the Center for Rehabilitation Outcomes Research and first author on the paper. “Many of our interviewees also mentioned the need for better compensation for direct service providers.”

According to the U.S Bureau of Labor Statistics, in 2023 DSPs made a median hourly wage of $16.12 and an annual wage of $33,530. “Without making a living wage, there is really high turnover among DSPs, and this impacts their ability to deliver truly person-centered services, and for HCBS users to build trust with their providers,” explains Tennety.

HCBS users also said they weren’t able to do things that were important to them because of provider turnover, and that they were acutely aware of the DSP workforce shortage. “I remember one interview in particular with an HCBS user who said that they would settle for a DSP they didn’t feel comfortable with or wanted to work with because they didn’t know when they would be able to find another person that was a better match,” says Tennety.

Resource issues identified by HCBS providers included insufficient state budgets and Medicaid reimbursement rates that didn’t align with users’ needs. Extensive waitlists for HCBS waivers and strict eligibility criteria were other barriers to the provision of HCBS mentioned by providers. Improved access to services, such as through telehealth, was noted as a way to eliminate some of these barriers. 

Interviewees also mentioned that sustaining flexibilities activated during the Covid-19 pandemic that allowed HCBS recipients to self-direct their services, including hiring family members, would also improve the person-centeredness of HCBS.

“Our interviews revealed multiple systems-level issues affecting the delivery of person-centered services,” says Bridgette Schram, PhD, a project manager in the Center for Rehabilitation Outcomes Research and an author on the paper. “Policy addressing person-centered practice implementation within systems reforms, beyond the direct providers and workforce, is needed to improve HCBS users’ quality of life in their communities.”  

Allen Heinemann, PhD, Jacqueline Kish, PhD, Tonie Sadler, PhD, Ross Kaine and Katie Kaufman of the Center for Rehabilitation Outcomes Research at Shirley Ryan AbilityLab and Steve Lutzky, PhD, of HCBS Strategies, are co-authors on the paper.

This research is supported by the national Institute for Disability, Independent Living and Rehabilitation Research (grant 90RTGE0004).

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Bridgette schram, phd, project manager in cror’s rehabilitation and research training center on hcbs, research informed by care: niveda tennety uses storytelling to inform work, episode 11: developing and testing person-centered hcbs outcome measures.