Chapter 4
Language Barriers and Access to Care
SEONAE YEO
ABSTRACT
The purpose of this chapter is to examine how language barriers contribute to
health disparities among ethnic and racial minorities in the United States. A
literature search was systematically conducted using selected computer databases
(MEDLINE and CINAHL). Searches were limited to English-language-published research in the years from 1985 to 2003. A total of 47 published articles
were included in this review. Overall these studies indicate that language barriers
are associated with longer visit time per clinic visit, less frequent clinic visits,
less understanding of physician’s explanation, more lab tests, more emergency
room visits, less follow-up, and less satisfaction with health services. The results
also indicate that people who are older, poorer, and female tend to have severe
language barriers compared to those who are younger, wealthier, and male.
Improvement of communication between patients and providers in relation to
health disparity consists of cultural competency and communication skills. Implications of these studies for practice and further research are outlined.
Keywords: access to care, cultural and linguistic competency, language
barriers
Language is the means by which a patient accesses the health care system,
learns about services, and makes decisions about her or his health behavior
(Woloshin, Schwartz, Katz, & Welch, 1997). Language is also the means
by which the health care provider accesses a patient’s beliefs about health
59
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FACTORS CONTRIBUTING TO HEALTH DISPARITIES
and illness, and thus creates an opportunity to address and reconcile different belief systems. In essence, communication between nurses and patients
is the heart of nursing care.
In the last twenty years, the United States has experienced a dramatic
increase in the number of people who speak a language other than English
as their primary language (U.S. Census Bureau, 2002). This is mainly
because during this time the United States has experienced a rapid increase
in the number of immigrants from Mexico and various countries from
Latin America and Asia. In the 1990s, the foreign-born population nearly
doubled to 31 million, or 11% of the 281 million that constitute the U.S.
population (Morse, 2002). Of the total foreign-born population, 51% were
born in Latin America and 25.5% were born in Asia. When both citizens
and noncitizens are combined, it is estimated that nearly 25 million adults
experience language barriers when they receive health care.
Within the broad Hispanic or Asian categories, the ethnic minority
groups in the United States are quite diverse. Within the 35 million counted
as Hispanic or Latino, more than half are Mexican; the remainder are
Puerto Rican, Cuban, Dominican, Costa Rican, Guatemalan, Honduran,
Nicaraguan, Panamanian, Salvadoran, Argentinean, Bolivian, Chilean, Colombian, Ecuadorian, Paraguayan, Peruvian, and Venezuelan. Though they
share a common language, Spanish, they differ vastly in their health beliefs,
behaviors, and lifestyles. Asian and Pacific Islander Americans (APIAs)
are estimated at 11 million (or 4% of the U.S. population), with almost
60 different national and ethnic origins, including such groups as Chinese,
Japanese, Korean, Mon-Khmer/Cambodian, Mian/Hmong, Thai, Laotian,
Vietnamese, and Tagalog. Each APIA possesses at least one unique language and usually multiple distinctively different cultures. Hispanics or
Asians who perceive language barriers when they access health care tend
to be new to the United States (D’Avanzo, 1992) and often do not have
commercial health insurance (Hampers, Cha, Gutglass, Binns, & Krug,
1999; Schur & Albers, 1996).
Differences in language between health care providers and patients
increasingly impose barriers to health care. The purpose of this critical
research review is to describe the relation of language barriers among
racial and ethnic minorities and to examine how language barriers may
contribute to health disparities among these populations. The Health Resources and Service Administration (HRSA) defines health disparity as a
population-specific difference in the presence of disease, health outcomes,
or access to care (Eliminating Health Disparities in the United States,
LANGUAGE BARRIERS AND ACCESS TO CARE
61
2001). Language barriers between patients and health care providers may
affect all three outcomes (i.e., disease incidence, health outcomes, or access
to care). This review focuses specifically on published studies that address
language barriers and access to care in an effort to address health disparities
in racial and ethnic minorities.
METHODS
A literature search was systematically conducted using selected computer
databases (MEDLINE and CINAHL). The databases were searched using
the following keywords with various logical connections: language, communication barrier, access to care, health service accessibility, health
disparity, and health outcome. Searches were limited to English-language
published research from 1985 to 2003.
RESULTS
A total of 47 articles were included in this review. Research studies
accounted for 28 of the articles (16 quantitative and 12 qualitative studies);
8 were review articles, and the others consisted of reports, consensus
statements, or position papers. Data-based articles conducted in the United
States form the basis for this review. Of these 16 quantitative studies, 11
studies were conducted in the United States, 3 were in Australia, 1 in
England, and 1 in Canada. Twelve articles report the results of qualitative
studies. Four of these studies were conducted in the United States, four
were in Australia, three in England, and one in Canada.
Only one study used a randomized trial method (Hornberger et al.,
1996). The other 10 quantitative studies included 4 cross-sectional studies
(Derose & Baker, 2000; David & Rhee, 1998; Feinberg, Swartz, Zaslavsky,
Gardner, & Walker, 2002; Meredith, Stewart, & Brown, 2001); 3 cohort
studies—1 retrospective (Jacobs et al., 2001) and 2 prospective (Hampers
et al., 1999; Kravitz, Helms, Azari, Antonius, & Melnikow, 2000); and 1
chart review (Heilemann, Lee, Stinson, Koshar, & Goss, 2000).
Overall, these studies indicate that language barriers are associated
with lack of awareness about health care benefits (such as Medicaid eligibility) (Feinberg et al., 2002), less insured status (Hampers et al., 1999),
longer visit time per clinic visit (Kravitz et al., 2000), less frequent clinic
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FACTORS CONTRIBUTING TO HEALTH DISPARITIES
visits (Derose & Baker, 2000), less understanding of the physician’s explanations (David & Rhee, 1998; Gerrish, 2001), more lab tests (Hampers et
al., 1999), more emergency room visits (Hampers et al., 1999), less followup (Kravitz et al., 2000), and less satisfaction with health services (Meredith
et al., 2001; Morales, Cunningham, Brown, Liu, & Hays, 1999). Because
these are observational studies (i.e., descriptive study design), no causal
relations can be established between a language barrier and these negative
consequences. Furthermore, none of the studies address how these negative
experiences are related to actual health outcomes or disease incidences.
In the following discussion section, the content of 47 articles is discussed
in an attempt to answer the research question: How do language barriers
contribute to health disparities among ethnic and racial minorities in the
United States?
DISCUSSION
A limited number of database studies provide a platform from which to
analyze possible relationships between language barrier, access to care,
and health outcomes. In order to examine these relationships, the characteristics of people with language barriers in the United States are summarized
from other sources so that potential spurious relationships can be identified.
Various translation services have been used to facilitate communication
in daily clinical settings, and the effectiveness of these translation services
is discussed. Lastly, research directions are suggested based on the results
of this review.
Characteristics of People with Language Barriers
In the reviewed articles, only a few studies conducted in the United States
concur that certain demographic factors are associated with the level of
English proficiency across races and ethnicities. Jacobs and colleagues
(2001) studied a total of 4,380 adults continuously enrolled in a health
maintenance organization for two years. Their descriptive data indicate
that those who did not speak English well enough were significantly older
(p < .01) and poorer (p < .01). In addition, more women than men tended
to have severe language barriers. Derose and Baker’s (2000) study of
Latinos (N = 724) also revealed that Latinos with limited English profi-
LANGUAGE BARRIERS AND ACCESS TO CARE
63
ciency (LEP) were older than Latinos with better English proficiency.
Further, Latinos with LEP were more likely to be female and to be less
literate than English speakers of all ethnicities.
Some groups of Asians, such as Japanese, are an exception to the
characteristics of persons with LEP previously described. Japanese are
often excluded from underserved populations because of their greater
similarity to non-Hispanic Whites in socioeconomic status. Yet Japanese
clients also identify language as the most difficult and obvious obstacle
to access to health care in the United States (Yeo, Fetters, & Maeda,
2000). Many Asians share similar disadvantages as Latinos when it comes
to language barriers (Carey Jackson et al., 2000; D’Avanzo, 1992; Gerrish,
2001; Meredith et al., 2001). Thus a language barrier, regardless of socioeconomic status, may be an independent factor that negatively affects
access to care.
Language Barriers and Access to Care
The consequences of language barriers range from miscommunication
(David & Rhee, 1998) to inefficient use of health care services (Hampers
et al., 1999; Kravitz et al., 2000). Some studies describe behavior due to
cultural beliefs without clearly differentiating it from behavior due to
language barriers (Carey Jackson et al., 2000; Derose & Baker, 2000;
Feinberg et al., 2002; Meredith et al., 2001). Culturally specific health
beliefs and behaviors must be considered separately from barriers related
to language. In other words, the use of translators does not in itself decrease
barriers to care.
As an example, one study (David & Rhee, 1998) compared the understanding of side effects of two groups (those who had good English skills
and those who either had poor English skills or brought translators) using
a written survey of yes/no questions. In this study, Spanish-speaking people
who had poor English skills regardless of having a translator had significantly less understanding of the side effects explained to them than those
with good English skills (41% vs. 16%). Researchers did not examine
whether language barriers or culturally specific health beliefs were the
reason for the lack of understanding. Both groups showed similar responses
regarding (1) how the understanding of side effects corresponded to compliance with medication; (2) the feeling that they had enough time to communicate with doctors; and (3) whether they received enough explanation
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FACTORS CONTRIBUTING TO HEALTH DISPARITIES
about preventive tests. Both groups also demonstrated a similar proportion
of people who took preventive tests in last 2 years.
Differences exist in the proportions of people who say (1) that they
understand the side effects of medication; (2) that they are satisfied with
medical care; and (3) that they feel that their doctor understands how they
feel. If the language was the only barrier, why did the translator fail to
explain the side effects of medication? Why are they less satisfied with
medical care? And why do they feel the doctor does not understand
how they feel? It is possible, though caution must be applied because of
overinterpretation, that side effects of medication, medical care, and doctor’s responses are difficult to comprehend because of the differences in
the health beliefs of patients and the health care system.
Language barriers have been linked to limited access to health services. For example, several studies have reported negative associations
between the presence of language barriers and the number of health care
visits (Derose & Baker, 2000; Feinberg et al., 2002; Jacobs et al., 2001).
Feinberg and others examined Medicaid enrollment of children in nonEnglish-speaking families. They report that those who did not speak English at home were less likely to be aware of Medicaid eligibility for their
children. The study did not indicate the effect on health outcomes; further
studies are necessary to determine this effect.
In contrast, some studies do not present a clear relationship between
the patient’s perception of health services (e.g., satisfaction with or acceptance of health service) and a language barrier (Carey Jackson et al., 2000;
Meredith et al., 2001; Morales et al., 1999). For example, the association
between adherence to various regimens and language barriers is not well
delineated. Brach and Fraser (2000), in their review article, attribute the
mixed findings to the literature’s failure to find a clear relationship between
general clinician-patient communication and adherence. Regardless of language barrier, communications between health care providers and patients
often involve misunderstanding, and thus poor compliance. Morales and
colleagues (1999) studied English- and Spanish-speaking Latinos in a
cross-sectional study (N = 7,093). They report that Latinos who responded
in Spanish were significantly more dissatisfied than Latinos who spoke
in English. Dissatisfaction was measured by five observations about medical staff: (1) they listen to what patients say; (2) they give answers to
questions; (3) they explain about prescribed medications; (4) they explain
about medical procedures and test results; and (5) they give reassurance
and support. It is important to note that dissatisfaction indicates the poor
LANGUAGE BARRIERS AND ACCESS TO CARE
65
quality of communication—but this may or may not be related to language barriers.
According to a national survey, 33% of Hispanics and 27% of Asians,
as compared to 16% of Whites and 23% of African Americans, reported
communication problems similar to the study’s results. Similarities included failing to understand their physician, feeling that their physician
did not listen to them, or declining to ask the physician questions about
their care. These statistics included both English- and non-English-speaking people. The study further reported that, among Hispanics, 43% of
non-English speakers had communication problems compared to 26% of
English-speaking Hispanics. Among Asians, these percentages were 39
and 25, respectively (Anonymous, 2002). It should be pointed out that
one in four minority patients who speak English have communication
problems with their doctors, compared to 16% of Whites. In sum, both
language barrier and minority status are associated with poor communication with care providers. The causal relationships among minority status,
language barriers, and perceived barriers to care are not well examined.
A few more insights into this relationship are provided by smallscale ethnographic studies. Focus group studies with content and semantic
analyses were conducted by Cave, Maharaj, Gibson, and Jackson (1995)
to improve cross-cultural communication in Edmonton, Canada. The results of this study provide rich qualitative information applicable to the
United States. The study involved recent immigrants from various countries
and a group of physicians who treated them. Patients were from Chile,
India, East Africa, and Jamaica. They had lived in Canada from 9 months
to 7 years. Both physicians and patients raised the problem of compliance;
however, the physicians questioned the patients’ compliance with prescribed medications, while the patients insisted they complied until the
point where they thought the treatment failed. The doctors felt that understanding the patients’ culture better would help achieve better diagnosis
and more effective management. The patients did not understand the intent
of the physicians’ questions about their culture and habits and sometimes
found such inquiries intrusive or irrelevant. Thus they did not disclose
personal information about themselves. At the same time, patients sometimes expected physicians to inherently know their perspective with little
or no explanation. These cultural differences can be viewed as barriers to
care, but they are not necessarily language barriers.
In efforts to understand the relation between language and health
outcomes, Heilemann and colleagues (2000) conducted a chart review in
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FACTORS CONTRIBUTING TO HEALTH DISPARITIES
rural northern California hospitals. The investigators compared perinatal
outcomes of 773 women of Mexican descent. They measured acculturation
in three different ways: by place of birth, by language spoken, and by the
two factors combined as on the acculturation index. The results indicated
that language spoken was a less useful indicator of perinatal outcome
complications than place of birth or the acculturation index. This study
intended to demonstrate that negative health outcomes are the result of
culturally determined health behaviors, not a language barrier. In this
study, language was not correlated with the degree of acculturation among
Latinos. A study by Meredith and colleagues (2001) comparing health
perspectives among different ethnic groups may give further insight into
the issue of language, culture, and health behaviors. In this study, Asian
and Pacific Islanders had better self-reported health, but they were less
satisfied and perceived less sharing in physician-patient relationships as
compared to Whites. A limitation of this study is that findings were not
analyzed by language proficiency, but only by ethnicity and race. Although
there is a significant percentage of Asians and Hispanics with LEP, it
is unclear how language barriers contributed to negative perceptions of
health encounters.
Thompson and others (2002) reported that Hispanics were much less
likely than non-Hispanic Whites to ever have had cancer screening. Socioeconomic status was explored as a predictor of differences between Hispanics and non-Hispanic Whites in cancer prevention behavior. In a crosssectional study, in-person interviews (N = 1,795) were conducted in a
population-based random sample of adults in 20 communities with a high
proportion of Hispanics. Hispanics were significantly less likely than nonHispanic Whites to ever have had cervical (p < 0.001), breast (p = 0.007)
or colorectal cancer screening (FOBT p = 0.008; sigmoidoscopy/colonoscopy p < 0.002). After adjusting for socioeconomic status (education and
having health insurance), only differences in cervical cancer remained
significant (p = 0.024). After adjusting for socioeconomic status, Hispanics
had a significantly higher intake of fruits and vegetables per day (4.84
servings) than non-Hispanic Whites (3.84 servings) (p < 0.001); and the
fat behavior score was marginally significant after adjustment for socioeconomic status (p = 0.053). Significantly fewer Hispanics were current smokers than non-Hispanic Whites (p < 0.001). The researchers concluded that
there is only limited support for the hypothesis that socioeconomic status
is a major determinant of some cancer-related behaviors. Specifically, in
this study, socioeconomic status was related to mammography and colo-
LANGUAGE BARRIERS AND ACCESS TO CARE
67
rectal screening, but not to cervical cancer, dietary behavior, or smoking.
Cancer screenings were lower in Hispanics regardless of the existence of
language barriers. The study did not assess health beliefs related to screening. This may have been a factor in the low rates of screening.
In addition, several studies demonstrate that language barriers result
in both inefficiency and potential increases in costs (Hampers et al., 1999;
Kravitz et al., 2000). For instance, Hampers indicates that patients with
language barriers have significantly higher test costs ($145 vs. $105) and
longer emergency department stays (165 minutes vs. 137 minutes) than
their English-speaking counterparts. Kravitz also demonstrated that Spanish- and Russian-speaking patients averaged 9.1 and 5.6 minutes longer
for visits, respectively, than English-speaking patients. Clearly, health
services must be made more effective and efficient for non-English-speaking patients.
Translation Services as a Solution
When a language barrier is identified between patient and care provider,
provision of various interpreter services is an obvious and frequently
proposed solution (Baker, Hayes, & Fortier, 1998; Poss & Beeman, 1999;
Tang, 1999; Woloshin, Bickell, Schwartz, Gany, & Welch, 1995; Zimmermann, 1997). Various approaches to interpretation exist, including on-site
professional interpreters, ad hoc interpreters (e.g., staff pulled away from
other duties to interpret, friends and family members, strangers from the
waiting room), and simultaneous remote interpretations using earphones
and microphones with off-site professional interpreters (Brach & Fraser,
2000).
The quality of interpretation depends on the adequacy of interpretation, the bilingual ability of staff, and the accuracy and content of a
competent medical interpretation (Woloshin et al., 1995). For example,
when patients have to rely on family members for interpretation, the
content of medical advice is often not fully understood (Gerrish, 2001)
and patients are less satisfied with the health service (Lee, Batal, Maselli, &
Kutner, 2002). Lee surveyed the satisfaction of English- and Spanishspeaking patients receiving acute care. Spanish speakers who had to rely
on family members or ad hoc interpreters were 54% and 49% less satisfied
than those who were provided AT&T telephone interpreters. Only a few
studies have examined the effect of translation service and access to health
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FACTORS CONTRIBUTING TO HEALTH DISPARITIES
care (Baker et al., 1998; Derose & Baker, 2000; Feinberg et al., 2002;
Jacobs et al., 2001; Lee et al., 2002). But no study in this review examined
the relationship between quality of interpretation service and disease incidence or improvement in compliance and health outcomes. Rather, the
studies assessed satisfaction and perception of care. These studies reasonably demonstrated, however, that translation services may improve access
to care, satisfaction with health care, and possibly adherence (Brach &
Fraser, 2000).
The current evidence indicates that simultaneous translation service
is an effective and satisfactory mode of translation (Hornberger et al.,
1996; Lee et al., 2002). According to Lee et al., patients who were provided
access to AT& T telephone interpretation services reported identical satisfaction to English-speaking patients. As a result, both patient and care
provider maintained higher-quality communication and perceived less disruption and more privacy. For example, Hornberger and others examined
the effectiveness of a remote-simultaneous interpretation system on the
communication between patients and physicians during routine postpartum
checkups on women who spoke only Spanish. They measured the quality
of communications by the outcome variables (i.e., satisfaction, number
of physician-mother utterances, and accuracy of translation) using taperecorded visits coded by trained native Spanish speakers who were fluent
in English. The results indicated that, compared to traditional translators
(control group), the number of utterances increased significantly among
patients and physicians (23% and 10%, respectively). In terms of accuracy
of translation, there were 12% fewer inaccuracies with the remote system
than with on-site translation with a translator. Both physicians and patients
preferred remote systems, giving reasons such as “feels more private” or
“less disruption by a third party.”
One study also evaluated the effectiveness of professionally trained
translators. Jacobs et al. (2001) studied the effects of a systematic professional interpretation service on access to health care. The study revealed
a significant increase in the number of office visits as well as the number
of prescriptions written and filled among patients who received a systematic
professional interpreter service on all occasions, including appointment
desk and lab visits. On-site provision of a comprehensive interpretation
service may be available at large facilities, but remote systems may be
more a realistic solution for many community-based clinics. A few available studies examined different types of translation services (Hornberger
et al., 1996; Lee et al., 2002). However, these studies were interested in
LANGUAGE BARRIERS AND ACCESS TO CARE
69
patient satisfaction. Further research is needed to examine the effect of
translation services on different health outcomes.
In summary, this critical research review found that language barriers
are more pronounced among older, poorer, less educated, and newer immigrants. Addressing language barriers is an obvious means to improve
access to health care among LEP persons. However, as these studies
indicated, this will not be sufficient. Research is needed to further determine
the effect of language on access to care, adherence to the regimens, quality
of health care, satisfaction, disease incidences, and health outcomes.
Future Research Directions
Based on this review, the following areas are identified as future research
needs. Among the three components that constitute a health disparity,
access to care has been most studied and thus is the focus of this review.
Access to care is analyzed from two aspects: exploration of interpretation
services and improvement of communication between patients and providers. The former may require relatively straightforward research methodologies when the outcomes are patient satisfaction. Currently only one
randomized control trial has been identified for this review. Similar studies
are needed to evaluate and support policy changes.
For example, national standards for culturally and linguistically appropriate services in health care (CLAS, 2001) are a means to correct the
inequities that currently exist in the provision of health services and to
make these services more responsive to the individual needs of all patients.
Further elaboration in designs and methodologies are required to determine
the causal relationship between choice of interpretation service and health
outcomes. Clinical trials need to be conducted to determine which interpretation services lead to better communication (i.e., access to care), change
behaviors (i.e., health outcomes), and ultimately reduce diseases. With
these reports, state and national health service policies must incorporate
the optimal interpretation services. When systems such as a telephone
translation service become widely available subsequent to policy changes,
large-scale epidemiological studies may address these relationships.
Improvement of communication between patients and providers involves more complex and daunting tasks, since this is a more pervasive
medical problem than language barriers alone. This issue involves cultural
competency and communication skills. We need qualitative studies in
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FACTORS CONTRIBUTING TO HEALTH DISPARITIES
cultural competency to develop more efficient models. Existing health
belief and behavior models in the United States must be scrutinized for
their cultural appropriateness before they are applied. A language barrier,
a component of cultural appropriateness, then is clearly identified and
analyzed in relation to other factors, which are closely related to it (Brach &
Fraser, 2000). These factors include the role of bilingual care providers
and an understanding of other health belief models.
Culture, defined as an “integrated pattern of human behavior that
includes thoughts, communications, actions, religious or social group”
(Cross et al., 1989), and language go hand-in-hand. Therefore, it is probably
necessary to view the language barrier through a cultural competency
model such as that of Brach and Fraser (2000). They propose a conceptual
model of how interpreter services could reduce health disparities, based
on their understanding of cultural competency. This model is by far the
most developed and detailed. There is a merit to examining the direct link
between language barriers and racial and ethnic health disparities because
provision of interpretation is a tangible yet costly hypothesized solution.
Other conceptual models, such as Anderson’s access-to-care model, can
be also used (Andersen, 1995; Andersen, Rice, & Kominski, 2001).
Historically, a language barrier was considered a disability, according
to the expansion of the Civil Rights Act of 1964 (Woloshin et al., 1995).
A language that has unique and fundamental characteristics of national
origin should thus be protected rather than punished. This view was upheld
by the Supreme Court in 1974; it thus enforced health programs funded
by the Department of Health and Human Services (DHHS) to provide
translation services to people with LEP. According to Woloshin, however,
this law had three problems: (1) the regulation was vague; (2) funds were
inadequate; and (3) enforcement was complaint-driven and ad hoc.
In 1997, the Office of Minority Health (OMH) undertook the development of more comprehensive national standards to provide culturally and
linguistically appropriate services (CLAS, 2001). The CLAS standards
were published in final form in the Federal Register on December 22,
2000, as recommended national standards for adoption or adaptation by
various organizations and agencies.
Although it is clear that adequate funding is needed to provide highquality translation services, currently only a handful of states reimburse
for outpatient use of interpreters via a Medicaid mechanism. Health care
providers in other states still put themselves at risk because they are
obligated to perform a proper health assessment without adequate re-
LANGUAGE BARRIERS AND ACCESS TO CARE
71
sources. The failure to do so can constitute negligence for which nurses
and other health care providers may be held liable if the patient suffers
some subsequent injury attributable to this failure (CLAS, 2001). In order to
implement and evaluate the latest national standards (i.e., CLAS), evidence
should be generated by studies with sound research designs and
methodologies.
ACKNOWLEDGMENT
The author thanks Ms. Katherine Roberts for her assistance in the literature review.
REFERENCES
Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care:
Does it matter? Journal of Health and Social Behavior, 36(1), 1–10.
Andersen, R. M., Rice, T. M., & Kominski, G. F. (2001). Changing the U.S. health
care system: Key issues in health services, policy, and management. San Francisco: Jossey-Bass.
Anonymous. (2002). Poor communications, cultural barriers impacting quality of health
care for minorities. Quality Letter for Healthcare Leaders, 14(4), 11–13.
Baker, D. W., Hayes, R., & Fortier, J. P. (1998). Interpreter use and satisfaction
with interpersonal aspects of care for Spanish-speaking patients. Medical Care,
36, 1461–1470.
Brach, C., & Fraser, I. (2000). Can cultural competency reduce racial and ethnic health
disparities? A review and conceptual model. Medical Care Research and Review,
57(Suppl 1), 181–217.
Carey Jackson, J., Taylor, V. M., Chitnarong, K., Mahloch, J., Fischer, M., Sam, R., &
Seng, P. (2000). Development of a cervical cancer control intervention program
for Cambodian American women. Journal of Community Health, 25, 359–375.
Cave, A., Maharaj, U., Gibson, N., & Jackson, E. (1995). Physicians and immigrant
patients. Cross-cultural communication. Canadian Family Physician, 41,
1685–1690.
CLAS. (2001). National standards for culturally and linguistically appropriate services
in health care: Final report (Report). Washington, DC: U.S. Department of
Health and Human Services, OPHS, Office of Minority Health.
Cross, T. L., Bazron, B. J., Dennis, K. W., & Isaacs, M. R. (1998). Towards a culturally
competent system of care: A monograph on effective services for minority children
who are severely emotionally disturbed. Washington, DC: CASSP Technical
Assistance Center, Georgetown University Child Development Center.
72
FACTORS CONTRIBUTING TO HEALTH DISPARITIES
D’Avanzo, C. E. (1992). Barriers to health care for Vietnamese refugees. Journal of
Professional Nursing, 8, 245–253.
David, R. A., & Rhee, M. (1998). The impact of language as a barrier to effective
health care in an underserved urban Hispanic community. Mount Sinai Journal
of Medicine, 65, 393–397.
Derose, K. P., & Baker, D. W. (2000). Limited English proficiency and Latinos’ use
of physician services. Medical Care Research and Review, 57(1), 76–91.
Eliminating health disparities in the United States. (2001). Rockville: Health Resources
and Service Administration.
Feinberg, E., Swartz, K., Zaslavsky, A. M., Gardner, J., & Walker, D. K. (2002).
Language proficiency and the enrollment of Medicaid-eligible children in publicly
funded health insurance programs. Maternal and Child Health Journal, 6(1), 5–18.
Gerrish, K. (2001). The nature and effect of communication difficulties arising from
interactions between district nurses and South Asian patients and their carers.
Journal of Advanced Nursing, 33, 566–574.
Hampers, L. C., Cha, S., Gutglass, D. J., Binns, H. J., & Krug, S. E. (1999). Language
barriers and resource utilization in a pediatric emergency department. Pediatrics,
103(6 Pt 1), 1253–1256.
Heilemann, M. V., Lee, K. A., Stinson, J., Koshar, J. H., & Goss, G. (2000). Acculturation and perinatal health outcomes among rural women of Mexican descent.
Research in Nursing and Health, 23, 118–125.
Hornberger, J. C., Gibson, C. D., Jr., Wood, W., Dequeldre, C., Corso, I., Palla, B., &
Bloch, D. A. (1996). Eliminating language barriers for non-English-speaking
patients. Medical Care, 34, 845–856.
Jacobs, E. A., Lauderdale, D. S., Meltzer, D., Shorey, J. M., Levinson, W., & Thisted,
R. A. (2001). Impact of interpreter services on delivery of health care to limitedEnglish-proficient patients. Journal of General Internal Medicine, 16, 468–474.
Kravitz, R. L., Helms, L. J., Azari, R., Antonius, D., & Melnikow, J. (2000). Comparing
the use of physician time and health care resources among patients speaking
English, Spanish, and Russian. Medical Care, 38, 728–738.
Lee, L. J., Batal, H. A., Maselli, J. H., & Kutner, J. S. (2002). Effect of Spanish
interpretation method on patient satisfaction in an urban walk-in clinic. Journal
of General Internal Medicine, 17, 641–645.
Meredith, L., Stewart, M., & Brown, J. B. (2001). Patient-centered communication
scoring method report on nine coded interviews [Comment]. Health Communication, 13(1), 19–31.
Morales, L. S., Cunningham, W. E., Brown, J. A., Liu, H., & Hays, R. D. (1999). Are
Latinos less satisfied with communication by health care providers? Journal of
General Internal Medicine, 14, 409–417.
Poss, J. E., & Beeman, T. (1999). Effective use of interpreters in health care: Guidelines
for nurse managers and clinicians. Seminars for Nurse Managers, 7, 166–171.
Schur, C. L., & Albers, L. A. (1996). Language, sociodemographics, and health care
use of Hispanic adults. Journal of Health Care for the Poor and Underserved,
7, 140–158.
LANGUAGE BARRIERS AND ACCESS TO CARE
73
Tang, S. Y. (1999). Interpreter services in healthcare. Policy recommendations for
healthcare agencies. Journal of Nursing Administration, 29(6), 23–29.
Thompson, B., Coronado, G. D., Solomon, C. C., McClerran, D. F., Neuhouser, M.
L., & Feng, Z. (2002). Cancer prevention behaviors and socioeconomic status
among Hispanics and non-Hispanic Whites in a rural population in the United
States. Cancer Causes & Control, 13, 719–728.
U.S. Census Bureau. (2000). Coming to America: A profile of the Nation’s Foreign
Born Census Brief: Current population survey. Washington, DC: U.S. Department
of Commerce, Economics and Statistics Administration.
Woloshin, S., Bickell, N. A., Schwartz, L. M., Gany, F., & Welch, H. G. (1995).
Language barriers in medicine in the United States. Journal of the American
Medical Association, 273, 724–728.
Woloshin, S., Schwartz, L. M., Katz, S. J., & Welch, H. G. (1997). Is language a
barrier to the use of preventive services? Journal of General Internal Medicine,
12, 472–477.
Yeo, S., Fetters, M., & Maeda, Y. (2000). Japanese couples’ childbirth experiences
in Michigan: Implications for care. Birth, 27, 191–198.
Zimmermann, P. G. (1997). Enhancing your use of interpreters. Nursing Spectrum
(D.C./Baltimore Metro Edition), 7(12), 12.