About This Literature Summary
This summary of the literature on Language and Literacy as a social determinant of health is a narrowly defined examination that is not intended to be exhaustive and may not address all dimensions of the issue. Please note: The terminology used in each summary is consistent with the respective references. For additional information on cross-cutting topics, please see the Health Literacy and High School Graduation literature summaries.
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Literature Summary
Language is defined as “the principal method of human communication, consisting of words used in a structure and conventional way and conveyed by speech, writing, or gesture.”1 Literacy has multiple components, including oral literacy (listening and speaking skills), print literacy (writing and reading skills), numeracy (the ability to understand and work with numbers), and cultural and conceptual knowledge.2,3 Literacy is distinct from health literacy, which has been defined by the U.S. Department of Health and Human Services (HHS) as the degree to which individuals and organizations find, understand, and use health-related information or services.4 Research indicates that limited language skills and low literacy skills are associated with lower educational attainment and worse health outcomes.5,6,7,8,9
This summary focuses on the health-related impact of language and literacy; see the High School Graduation literature summary for more information about the health-related impact of educational attainment.
Certain groups are at higher risk for having limited English language skills and low literacy, such as individuals who do not speak English at home, immigrants, and individuals with lower levels of education. In 2019, an estimated 21.6 percent of the United States population age 5 years or older spoke a language other than English at home.10 Among these individuals, 61 percent reported they spoke English “very well” and 39 percent reported speaking English less than very well (“well,” “not well,” or “not at all”).10 The U.S. National Adult Literacy Survey found that while almost 100 percent of individuals who immigrated to the United States between the ages of 1 and 11 years self-reported being fluent in English, approximately one-third of individuals who immigrated to the United States when they were age 12 years or older reported that they were not fluent in English — although this figure varied significantly by race/ethnicity, age at immigration, and amount of formal education prior to entering the United States.11 The same study found that for English-only speakers, literacy scores increased by educational attainment, with scores varying by level of educational attainment more than by ethnicity or immigrant status.11
Having limited English proficiency in the United States can be a barrier to accessing health care services and understanding health information.2 For example, those who identify as having limited English proficiency are less likely to have a usual place to go to when sick or have a preventive care visit in the past year.12 A study that examined self-reported health status among Hispanic adults in the United States found that Mexican, Puerto Rican, Cuban, Dominican, and other Hispanic people who chose to respond to a survey in Spanish were more likely to report a poor/fair health status than their counterparts who responded to the survey in English.13
Likewise, literacy and health are interconnected. Limited literacy is a barrier to accessing health information, proper medication use, and utilization of preventive services.14,15,16 Individuals with limited literacy face additional difficulties following medication instructions, communicating with health care providers, and attaining health information — all of which may adversely affect their health.9,17,18,19,20,21 Research has also shown a positive correlation between limited literacy skills and chronic conditions, including diabetes and cancer.2,15
Institutional barriers such as a lack of well-trained interpreters and culturally competent health care providers adversely affect the health of individuals with low literacy and limited English proficiency. For immigrants dealing with language and literacy challenges, cultural barriers and financial difficulties may create additional obstacles to accessing and comprehending health information.22 Quality of care is lowered when patients do not understand their health care providers, when patients and providers do not speak the same language, and when a provider’s approach is not linguistically competent.23,24,25 Patients with limited English proficiency may receive lower-quality mental health care due to inadequate interpretation services, as interpreters may “normalize” or omit pathological symptoms from their interpretations.26 However, trained interpreters and bilingual health care providers improve patient satisfaction, quality of care, and health outcomes for individuals with limited English proficiency.24,26 Overall, there is a need for health care providers and organizations to be more active in developing and employing strategies to meet the language and literacy needs of people with limited literacy and English proficiency, especially in online, written communication.28
Additional research is needed to increase the evidence base regarding the relationship between language, literacy, and health outcomes. This additional evidence will facilitate public health efforts to address language and literacy as social determinants of health.
