IMMIGRATION STATUS, LANGUAGE AND NATIONALITY 101

What are we talking about when we talk about immigration status, language and nationality?

Immigration status: Immigration status is a way of characterizing someone’s presence in a country. In the United States, examples of immigration status include citizen (by birth or naturalization), legal permanent or conditional permanent resident, non-immigrant (present on temporary visas, such as student visas), and undocumented immigrant. Everyone has an immigration status, and people can move between immigration statuses (Esperanza United).

Language: Language refers to a system that people use to communicate as part of a social group and culture. Most people learn to send and receive the symbols of language during their childhood. Each person develops a unique communication system, and when two people’s communication systems are too far apart for them to understand each other, these people are typically considered to speak different languages (Robins and Crystal, 2022).

Nationality: Nationality refers to membership in a country or nation, whether by birth, length of stay, naturalization, lineage, or other political or social definitions. The UN considers nationality a human right (Encyclopedia Britannica, 2023). Still, many people lack a nationality, which can impact their ability to access basic needs like health care (Kingston et al., 2010). Nationality is distinct from ethnic or cultural background; people who share a nationality may differ in their beliefs, practices, languages, or norms.

Why do immigration status, language and nationality matter in healthcare?

Although people should never be reduced to their immigration status, immigration status can be an important factor to consider in health care. In 2019, about 14% of the U.S. population was born outside the country. People’s reasons for migration–and the experience of migration itself–can be sources of significant stress. Moreover, immigration status is often tied to a person’s employment eligibility, health insurance coverage, and access to resources (Hill, 2021). To provide continuous and sustainable care, it is important to tailor health care to a patient’s specific context.

Language and nationality may also impact care. Language barriers can lead to lower quality of care, poor health outcomes, and low patient and physician satisfaction, as well as to low patient safety (Shamsi et al., 2020). One reason for these effects of language barriers is that language strongly impacts patients’ health literacy, or their ability to understand and act on health information (Partida, 2012). A report by the Institute of Medicine estimates that over 47% of U.S. adults have low health literacy (2004). If an English-speaking American has difficulty comprehending and acting on health information, the case is worse for individuals who lack English proficiency, and who in many cases face other health barriers (Partida, 2012). The use of interpreters can help alleviate language barriers, but it alone cannot bolster health literacy if cultural context is not taken into account. For instance, cross-cultural differences in the manifestation and perception of disease can affect patients’ descriptions of their chief complaint (Khambaty and Parikh, 2017).

What do we know about immigration status, language and nationality in medical and health professions education?

One way that educators influence students’ learning in medical and health professions education is through the language they use to discuss people of diverse linguistic backgrounds and nationalities. Overgeneralizations based on nationality may lead to “race-based diagnosis.” For example, an educator may present sickle-cell anemia as a disease associated with African immigrants rather than as a disease common among people living in locations with prevalent malaria (Amutah et al, 2021). These overgeneralizations may also lead to the presentation of “prevalence without context”: an educator may say that non-English speakers are less likely to take their medication without discussing the context of poor language proficiency, inadequate access to health services, and other determinants of health (Amutah et al, 2021).

Changes to educational curricula can help students provide equitable health care to people of different immigration statuses, linguistic backgrounds, and nationalities. For instance, authors have called for increased education about the refugee experience and the effect of the conditions of someone’s home country on their health. They have also noted the need to teach students who may encounter language barriers about the importance of using interpreters, as well as how to use nonverbal communication effectively (Koehn & Swick, 2006). 

How does the Bias Checklist address immigration status, language and nationality in health professions education content?

The Bias Checklist first asks: 

  • “Does the content include any mention of immigration status, language and nationality?”

If you answer no, you will be prompted to consider whether your content should mention immigration status, language and/or nationality. 

The Bias Checklist then asks the following specific questions about content:

  • “Does this content distinguish between different categories of immigration status, including refugees, asylum seekers, and undocumented immigrants, ‘green card holders’, etc.?”

  • “Could this content be understood as suggesting that patients who do not speak English are less capable of understanding healthcare information, making informed healthcare decisions or adhering to healthcare recommendations?”

Below are some examples of common ways in which bias, shame, stereotype and stigma toward immigration status, language and nationality can manifest in health professions education content:

  • Focusing only on language barriers in clinical encounters between physicians and patients who are immigrants (assumes immigrants never speak English and neglects other important features of the encounter)

  • Overemphasizing the burden on healthcare providers' time related to use of interpreter

  • Assuming or implying that all Spanish-speaking patients are undocumented immigrants / migrant workers

  • Any comment about this subject that is meant to elicit laughter

Last, the Checklist asks: 

  • “Could the content be perceived as promoting stereotypes, bias, shame or stigma?”

What can we do to address this problem?

  • Example: The majority of incidents of immigration bias reported to the Bias Checklist include repeatedly describing immigrants as “unvaccinated.” Some questions or vignettes that describe people from outside the US as being unvaccinated should be altered. This way, they could avoid reinforcing the assumption that immigrants did not receive vaccines or other aspects of health care before moving to the US.

  • Example: The only question that mentions immigrants on a USMLE practice exam asks who should serve as an interpreter for a woman with limited English proficiency. The focus of this question implies that the primary issue in an encounter with an immigrant is a language barrier. This content could be revised to include more questions mentioning immigrants that do not make a language barrier the focus of the encounter. Click here to view the question (#50).

Where can I go to learn more? 

I learn best by…

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Need a consultation?

The following people have identified themselves as experts in this domain and are willing to be contacted with questions regarding your content.

  • Health care and health policy for undocumented patients: Rachel Fabi, PhD, Associate Professor of Bioethics and Humanities, SUNY Upstate Medical University (fabir@upstate.edu)

  • Health care for refugees: Andrea Shaw, MD, Assistant Professor of Pediatrics, SUNY Upstate Medical University (shawan@upstate.edu) 

Have something to add? 

Email us at biaschecklist@gmail.com with any of the following:

  • Recommendations for additional important content to include above, or suggested corrections or clarifications → use the subject header “Immigration Status, Language and Nationality 101 - Correction”

  • Suggestions for additional questions to add to the Bias Checklist → use the subject header “Immigration Status, Language and Nationality 101 - Checklist Question”

  • Suggestions for additional resources for learning more → use the subject header “Immigration Status, Language and Nationality 101 - Learn More”

  • Examples of curricular bias, including before and after versions of content → use the subject header “Immigration Status, Language and Nationality 101 - Example”

  • Your name, credentials, affiliation, area(s) of expertise, and brief biography or summary of qualifications if you are willing to serve as an expert consultant → use the subject header “Immigration Status, Language and Nationality 101 - Consultant”

References

  1. Esperanza United. What is immigration status? Retrieved September 10, 1013, from https://esperanzaunited.org/en/knowledge-base/content-type/what-is-immigration-status/

  2. Robins, R. Henry, & Crystal, David (2022, August 18). Language. Encyclopedia Britannica. https://www.britannica.com/topic/language

  3. The Editors of Encyclopedia Britannica (2023, June 6). Nationality. https://www.britannica.com/topic/nationality-international-law

  4. Kingston, L. N., Cohen, E. F., & Morley, C. P. (2010). Debate: Limitations on universality: the "right to health" and the necessity of legal nationality. BMC International Health and Human Rights, 10(11). https://doi.org/10.1186/1472-698X-10-11

  5. Hill, Jessica, et al. (2021). Immigration status as a health care barrier in the USA during COVID-19. Journal of Migration and Health, 4. https://doi.org/10.1016/j.jmh.2021.100036

  6. Al Shamsi, H., et al. (2020). Implications of Language Barriers for Healthcare: A Systematic Review. Oman Medical Journal, 35(2), e122. https://doi.org/10.5001/omj.2020.40

  7. Partida, Yolanda. (2012). Language and health care. Diabetes Spectrum, 25(1). 

  8. Institute of Medicine (US) Committee on Health Literacy. (2004). Health Literacy: A Prescription to End Confusion. National Academies Press (US).

  9. Khambaty, M., & Parikh, R. M. (2017). Cultural aspects of anxiety disorders in India. Dialogues in Clinical Neuroscience, 19(2), 117–126. https://doi.org/10.31887/DCNS.2017.19.2/rparikh

  10. Amutah, C., et al. (2021). Misrepresenting Race - The Role of Medical Schools in Propagating Physician Bias. The New England Journal of Medicine, 384(9), 872–878. https://doi.org/10.1056/NEJMms2025768

  11. Koehn, Peter H, & Swick, Herbert M. (2006). Medical Education for a Changing World. Academic Medicine, 81(6). 10.1097/01.ACM.0000225217.15207.d4

contributing writer(s)

Mugabo Nshimiye, MD Candidate

Sophie Pollack-Milgate, BA

last updated October 4, 2023