Language and Literacy
The Healthy People 2020 Social Determinants of Health topic area is organized into 5 place-based domains:
- Economic Stability
- Health and Health Care
- Neighborhood and Built Environment
- Social and Community Context
Language and Literacy are key issues in the Education domain.
Language is defined as “the method of human communication, either spoken or written, consisting of the use of words in a structured and conventional way.” 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 have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions.”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. Data from the 2011 American Community Survey indicated that 60.6 million (21%) of the 291.5 million people in the United States age 5 or older spoke a language other than English at home.10 A majority (58%) of individuals who spoke a language other than English at home reported they spoke English “very well.”10 The remaining respondents who spoke a language other than English at home reported speaking English “well” (19%), “not well” (15%), or “not at all” (7%).10 The U.S. National Adult Literacy Survey found that while almost 100% of individuals who immigrated to the United States between the ages of 1 and 11 self-reported being fluent in English, approximately one-third of individuals who immigrated to the United States when they were age 12 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, compared to older individuals who only speak English, older individuals with limited English proficiency are more likely to have no usual source of care, report lower self-rated health, and report feeling sad most or all of the time.12 A study that examined self-reported health status, health behaviors, access to care, and timeliness of care among the U.S. Hispanic adult population found that Hispanic people who chose to respond to a survey in Spanish were more likely to report worse health status, lack health insurance, not have a personal doctor, and postpone seeing a doctor because of the cost of care, compared to Hispanic people who chose to respond in English.13
Likewise, literacy and health are interconnected. Limited literacy is a barrier to health knowledge access, proper medication use, and utilization of preventive services.14-17 Individuals with limited literacy face additional difficulties following with medication instructions, communicating with health care providers, and attaining health information—all of which may adversely affect their health.9, 18, 19, 20, 21, 22 Research has also shown a positive correlation between limited literacy skills and chronic conditions, including diabetes and cancer.2, 16
Institutional barriers such as a lack of well-trained interpreters and culturally competent health care providers adversely affects 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.23 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.24, 25, 26 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.27 However, trained interpreters and bilingual health care providers improve patient satisfaction, quality of care, and health outcomes for individuals with limited English proficiency.25, 27 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 diverse populations, including via online, written communication.14, 28, 29
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.
Disclaimer: This summary of the literature on language and literacy as a social determinant of health is a narrowly defined review that may not address all dimensions of the issue.i, ii Please keep in mind that the summary is likely to evolve as new evidence emerges or as additional research is conducted.
i Terminology used in the summary is consistent with the respective references. As a result, there may be variability in the use of terms, for example, black versus African American.
ii The term minority, when used in a summary, refers to racial/ethnic minority, unless otherwise specified.
1 English Oxford living dictionaries. 2017 Oct 30. Available from: https://en.oxforddictionaries.com/definition/language.
2 Nielsen-Bohlman L, Panzer AM, Kindig DA, editors. Health literacy: a prescription to end confusion. National Academies Press; 2004.
3 Kirsch IS. The framework used in developing and interpreting the International Adult Literacy Survey (IALS). EJPE. 2001;16(3):335–61.
4 U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. Washington, (DC): Author; 2010.
5 The Annie E. Casey Foundation. Early warning! Why reading by the end of third grade matters. Baltimore (MD): Author; 2010. Available from: http://www.aecf.org/m/resourcedoc/AECF-Early_Warning_Full_Report-2010.pdf.
6 U.S. Department of Education, America Reads Challenge. Start early, finish strong: How to help every child become a reader. Washington, (DC): U.S. Department of Education; 1999.
7 National Research Council. Preventing reading difficulties in young children. National Academies Press; 1998.
8 Hernandez DJ. Double jeopardy: how third-grade reading skills and poverty influence high school graduation. Baltimore, (MD): the Annie E. Casey Foundation; 2011.
9 Lincoln AK, Arford T, Doran MV, Guyer M, Hopper K. A preliminary examination of the meaning and effect of limited literacy in the lives of people with serious mental illness. J Community Psychol. 2015;43(3): 315-20. doi:10.1002/jcop.21680
10 Ryan C. Language use in the United States: 2011. American community survey reports. 2013;22:1–16.
11 Greenberg E, Macías RF, Rhodes D, Chan,T. English literacy and language minorities in the United States. Education Statistics Quarterly. 2001;3(4):73–5.
12 Ponce NA, Hays RD, Cunningham WE Linguistic disparities in health care access and health status among older adults. J Gen Intern Med. 2006;21(7):786–91. doi:10.1111/j.1525-1497.2006.00491.x
13 DuBard CA, Gizlice Z. Language spoken and differences in health status, access to care, and receipt of preventive services among US Hispanics. Am J Public Health. 2008;98(11): 2021–2028. doi:10.2105/ajph.2007.119008
14 Andrulis DP, Brach C. Integrating literacy, culture, and language to improve health care quality for diverse populations. Am J Health Behav, 2007;31(Suppl 1): S122-S133.
15 Kripalani S, Henderson LE, Chiu EY, Robertson R, Kolm P, Jacobson TA. Predictors of medication self‐management skill in a low‐literacy population. J Gen Intern Med. 2006;21(8): 852–56.
16 DeWalt DA, Berkman ND, Sheridan SL, Lohr KN, Pignone MP. Literacy and health outcomes. J Gen Intern Med. 2004;19(12):1228–39.
17 Berkman ND., Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, Holland A. Health literacy interventions and outcomes: an updated systematic review. 2011;1–941. Report no.: 199.
18 Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114(4):1008–15.
19 Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, Bindman AB. Association of health literacy with diabetes outcomes. JAMA. 2002;288(4): 475–82.
20 Gazmararian JA, Williams MV, Peel J, Baker DW. Health literacy and knowledge of chronic disease. Patient Educ Couns. 2003:51(3):267–75.
21 Katz MG, Jacobson TA, Veledar E, Kripalani S. Patient literacy and question-asking behavior during the medical encounter: a mixed-methods analysis. J Gen Intern Med. 2007;22(6):782–86.
22 Powell CK, Hill EG, Clancy DE. The relationship between health literacy and diabetes knowledge and readiness to take health actions. Diabetes Educ. 2007;33(1):144–151.
23 Kreps GL, Sparks L. Meeting the health literacy needs of immigrant populations. Patient education and counseling. Patient Educ Couns. 2008;71(3): 328–32.
24 Anderson LM, Scrimshaw SC, Fullilove MT, Fielding JE, Normand J. Culturally competent healthcare systems. A systematic review. Am J Prev Med. 2003;24(3 Suppl), 68–79.
25 Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57(1 Suppl):181–217.
26 Woloshin S, Bickell NA, Schwartz LM, Gany F, Welch HG. Language barriers in medicine in the United States. JAMA. 1995;273(9):724–28.
27 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. doi:10.1177/1077558705275416
28 Neuhauser L, Kreps GL. Online cancer communication: meeting the literacy, cultural and linguistic needs of diverse audiences. Patient Educ Couns. 2008;71(3): 365–77.
29 Villaire M, Mayer G. Low health literacy: the impact on chronic illness management. Prof Case Manag. 2007;12(4):213–16.