Language and Literacy

Education Access and Quality

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. 

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.14,15,16,17 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.9,18,19,20,21,22  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 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.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.



Oxford University Press. (2022). Definition of language.


Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (Eds.). (2004). Health literacy: A prescription to end confusion. National Academies Press.


Kirsch, I. S. (2001). The framework used in developing and interpreting the International Adult Literacy Survey (IALS). European Journal of Psychology of Education, 16(3), 335–361. doi: 10.1007/BF03173187


Office of Disease Prevention and Health Promotion. (2021). Health literacy in Healthy People 2030. U.S. Department of Health and Human Services.


Annie E. Casey Foundation. (2010). Early warning! Why reading by the end of third grade matters.


U.S. Department of Education, America Reads Challenge. (1999). Start early, finish strong: How to help every child become a reader.


National Research Council. (1998). Preventing reading difficulties in young children. National Academies Press.


Hernandez, D. J. (2011). Double jeopardy: How third-grade reading skills and poverty influence high school graduation. Annie E. Casey Foundation.


Lincoln, A. K., Arford, T., Doran, M. V., Guyer, M., & Hopper, K. (2015). A preliminary examination of the meaning and effect of limited literacy in the lives of people with serious mental illness. Journal of Community Psychology, 43(3), 315–320. doi: 10.1002/jcop.21680


United States Census Bureau, American Community Survey. (2019). 2019: ACS 5-year estimates data profile. 


Greenberg, E., Macías, R. F., Rhodes, D., & Chan, T. (2001). Literacy and language minorities in the United States. Education Statistics Quarterly, 3(4), 73–75.


Gulati, R. K., & Hur, K. (2022). Association between limited English proficiency and healthcare access and utilization in California. Journal of Immigrant and Minority Health, 24(1), 95–101. doi: 10.1007/s10903-021-01224-5 


Santos-Lozada, A. R., & Martinez, M. J. (2018). How have you been? or ¿Como estás?: Does language of interview influences self-rated health among Hispanic subgroups?. Journal of Immigrant and Minority Health, 20(4), 766–775. doi: 10.1007/s10903-017-0606-4


Andrulis, D. P., & Brach, C. (2007). Integrating literacy, culture, and language to improve health care quality for diverse populations. American Journal of Health Behavior, 31(1), S122–S133.


Kripalani, S., Henderson, L. E., Chiu, E. Y., Robertson, R., Kolm, P., & Jacobson, T. A. (2006). Predictors of medication self‐management skill in a low‐literacy population. Journal of General Internal Medicine, 21(8), 852–856. doi: 10.1111/j.1525-1497.2006.00536.x 


DeWalt, D. A., Berkman, N. D., Sheridan, S., Lohr, K. N., & Pignone, M. P. (2004). Literacy and health outcomes. Journal of General Internal Medicine, 19(12), 1228–1239. doi: 10.1111/j.1525-1497.2004.40153.x


Berkman, N. D., Sheridan, S. L., Donahue, K. E., Halpern, D. J., Viera, A., Crotty, K., ... & Viswanathan, M. (2011). Health literacy interventions and outcomes: An updated systematic review. Evidence Report/technology Assessment, (199), 1–941.


Williams, M. V., Baker, D. W., Honig, E. G., Lee, T. M., & Nowlan, A. (1998). Inadequate literacy is a barrier to asthma knowledge and self-care. Chest, 114(4), 1008–1015. doi: 10.1378/chest.114.4.1008


Schillinger, D., Grumbach, K., Piette, J., Wang, F., Osmond, D., Daher, C., ... & Bindman, A. B. (2002). Association of health literacy with diabetes outcomes. JAMA, 288(4), 475–482. doi: 10.1001/jama.288.4.475


Gazmararian, J. A., Williams, M. V., Peel, J., & Baker, D. W. (2003). Health literacy and knowledge of chronic disease. Patient Education and Counseling, 51(3), 267–275. doi: 10.1016/S0738-3991(02)00239-2


Katz, M. G., Jacobson, T. A., Veledar, E., & Kripalani, S. (2007). Patient literacy and question-asking behavior during the medical encounter: A mixed-methods analysis. Journal of General Internal Medicine, 22(6), 782–786. doi: 10.1007/s11606-007-0184-6


Powell, C. K., Hill, E. G., & Clancy, D. E. (2007). The relationship between health literacy and diabetes knowledge and readiness to take health actions. The Diabetes Educator, 33(1), 144–151. doi: 10.1177/0145721706297452


Kreps, G. L., & Sparks, L. (2008). Meeting the health literacy needs of immigrant populations. Patient Education and Counseling, 71(3), 328–332.


Anderson, L. M., Scrimshaw, S. C., Fullilove, M. T., Fielding, J. E., Normand, J., & Task Force on Community Preventive Services. (2003). Culturally competent healthcare systems: A systematic review. American Journal of Preventive Medicine, 24(3), 68–79. doi: 10.1016/S0749-3797(02)00657-8


Brach, C., & Fraserirector, 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. doi: 10.1177/1077558700057001S09


Woloshin, S., Bickell, N. A., Schwartz, L. M., Gany, F., & Welch, H. G. (1995). Language barriers in medicine in the United States. JAMA, 273(9), 724–728. doi: 10.1001/jama.1995.03520330054037


Flores, G. (2005). The impact of medical interpreter services on the quality of health care: A systematic review. Medical Care Research and Review, 62(3), 255–299. doi: 10.1177/1077558705275416


Neuhauser, L., & Kreps, G. L. (2008). Online cancer communication: Meeting the literacy, cultural, and linguistic needs of diverse audiences. Patient Education and Counseling, 71(3), 365–377. doi: 10.1016/j.pec.2008.02.015


Villaire, M., & Mayer, G. (2007). Low health literacy: The impact on chronic illness management. Professional Case Management, 12(4), 213–216. doi: 10.1097/01.PCAMA.0000282907.98166.93

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