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The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review

Sylvia E. Twersky
Rebeca Jefferson
Lisbet Garcia-Ortiz
Erin Williams
1 and
Carol Pina
Department of Public Health, The College of New Jersey, Ewing Township, NJ 08618, USA
R. Barbara Gitenstein Library, The College of New Jersey, Ewing Township, NJ 08618, USA
Author to whom correspondence should be addressed.
Healthcare 2024, 12(3), 364;
Submission received: 29 December 2023 / Revised: 24 January 2024 / Accepted: 25 January 2024 / Published: 31 January 2024


A majority of individuals with limited English proficiency (LEP) in the U.S. are foreign-born, creating a complex intersection of language, socio-economic, and policy barriers to healthcare access and achieving good outcomes. Mapping the research literature is key to addressing how LEP intersects with healthcare. This scoping review followed PRISMA-ScR guidelines and included PubMed/MEDLINE, CINAHL, Sociological Abstracts, EconLit, and Academic Search Premier. Study selection included quantitative studies since 2000 with outcomes specified for adults with LEP residing in the U.S. related to healthcare service access or defined health outcomes, including healthcare costs. A total of 137 articles met the inclusion criteria. Major outcomes included ambulatory care, hospitalization, screening, specific conditions, and general health. Overall, the literature identified differential access to and utilization of healthcare across multiple modalities with poorer outcomes among LEP populations compared with English-proficient populations. Current research includes inconsistent definitions for LEP populations, primarily cross-sectional studies, small sample sizes, and homogeneous language and regional samples. Current regulations and practices are insufficient to address the barriers that LEP individuals face to healthcare access and outcomes. Changes to EMRs and other data collection to consistently include LEP status and more methodologically rigorous studies are needed to address healthcare disparities for LEP individuals.

1. Introduction

1.1. Background

Language differences are a critical barrier to healthcare access as well as healthcare quality and effective outcomes. The U.S. Department of Justice defines limited English proficiency (LEP) as individuals who do not speak English as their primary language and who have a limited ability to read, speak, write, or understand English [1]. However, the medical literature often frames this differently since if electronic medical records capture LEP at all, it is often only in the form of the primary language spoken. Because of this, research studies looking at LEP use a range of definitions for determining LEP populations.
The primary language spoken may also be used as a proxy indicator for immigrant status, which is not often captured in medical data, despite immigrants being a vulnerable population for poor health outcomes due to reduced access to primary care [2,3,4]. Immigration patterns shape the LEP population in the U.S., as the majority of LEP individuals are foreign-born [5]. In the United States, 8.4% of households spoke English less than very well in 2022. The proportion of the population with LEP in the U.S. varies by language group, with the largest LEP population among Spanish speakers. According to the 2022 American Community Survey, 5.3% of Spanish speakers have LEP. The language groups with the second highest percentage are Chinese and Indo-European language speakers (0.6%), then other Asian and Pacific language speakers (0.4%), followed by Vietnamese and Russian, Polish, or other Slavic speakers (0.3%), and French, Haitian, or Creole, Korean, Tagalog, and Arabic speakers (0.2%), and lastly German or other West Germanic language speakers (0.1%) [6]. Linguistic diversity within the U.S. population, as well as the complex intersection of language with healthcare access, patient-provider communication, and socio-economic barriers, necessitate an in-depth examination of how LEP influences healthcare outcomes.
LEP individuals may encounter challenges accessing high-quality healthcare services, potentially leading to delays in care, medical errors, difficulty understanding and following provider directions, and other stumbling blocks to good health outcomes. Even the magnitude of the effect of adverse events can be greater for LEP populations, as evidenced by the fact that medical errors experienced by LEP individuals were more likely to cause physical harm compared to those experienced by patients who spoke English [7]. Recognizing this disparity, Title VI of the Civil Rights Act of 1964 was determined by the Supreme Court to cover LEP individuals and ensure that they are not discriminated against, and the Office for Civil Rights has the authority to investigate complaints and even withhold federal funds related to linguistic access [8]. In 2000, renewed attention was given to Title VI with Executive Order 13166, Improving Access to Services for Persons with Limited English Proficiency. This federal policy required all healthcare providers that received federal funds, including Medicare and Medicaid, to examine their policies and assess them for meaningful access to services by LEP individuals [9]. While this and other federal laws explicitly require access to language services such as interpretation and translation of documents in healthcare, a lack of knowledge and enforcement leave many LEP individuals without access to these key services. There are a few states that have large LEP populations, including California, Texas, Florida, and New York [10]. Because of this impact, these and other states have enacted their own supplemental statutes and regulations that try to help clarify and broaden access to quality healthcare for LEP individuals. As of 2019, every state in the U.S. has at least three provisions regarding language access in healthcare, although the specifics vary from comprehensive laws to (more commonly) laws that address only specific populations, providers, or healthcare modalities. California has the most comprehensive legislation, with 257 provisions in effect [11]. LEP populations can face significant disparities in health outcomes due to linguistic barriers and their intersection with other barriers, such as lack of health insurance and discrimination. Many LEP populations are also people of color, with LEP further exacerbating barriers many racial/ethnic groups already experience in the United States. For example, the LEP population in the U.S. is three times as likely as the English-proficient population to be uninsured [10].

1.2. Rationale for the Current Study

Some studies have shown that LEP is associated with poor asthma outcomes and higher healthcare resource utilization [12,13,14]. Multiple studies show that LEP is independently associated with lower use of preventive healthcare, poorer health behaviors linked to chronic disease, and a longer length of hospital stay for diabetes diagnoses [15,16,17]. However, the literature on hospital utilization is mixed, showing that the LEP population has an overall lower number of Emergency Department visits due to preventable causes such as asthma and diabetes than their English-proficient counterparts [18], is less likely to be admitted to the hospital for ambulatory-sensitive conditions from the ED [19], and has lower rates of diagnosed chronic disease [15]. The disparities among outcomes may occur because studies often focus on one specific geographic region within the U.S. and/or specific language groups and their experiences with the healthcare system. It then becomes even more important to understand and map the research literature in terms of LEP definitions, healthcare settings, geographic regions studied, linguistic groups that are included/excluded, and outcomes that are assessed in order to make sense of differences in the literature and potential gaps for LEP experiences and outcomes within the multimodal healthcare system.

1.3. Objectives

This review aims to provide a critical overview of the role that limited English proficiency (LEP) can play in determining healthcare outcomes across multiple domains in the U.S. healthcare system, including disease screening, ambulatory care access and outcomes, hospital utilization and outcomes, general health measures, and outcomes for specific conditions. Our review will focus on adults in a U.S. context and on spoken language. While definitions of LEP and healthcare literacy certainly can and do include written language, practically speaking, U.S. electronic medical records typically contain only information regarding the primary language spoken; therefore, it makes sense to keep this focus in our chosen context. Because we aim to map the literature on this topic and identify gaps, the scoping review methodology is the best fit for our objectives. By synthesizing insights from previous research, we can identify gaps in current knowledge and contribute to the research-based policy and practice decisions made to address healthcare disparities related to linguistic barriers.

2. Methods

2.1. Literature Sources and Search Strategy

An overall procedure was developed by the PI and study team in cooperation with the librarian author, following PRISMA-ScR guidelines. Please see supplementary materials for the PRISMA-ScR checklist. Our search strategy was designed to cover a broad range of healthcare modalities, looking specifically at health outcomes, and as such, included the clinical research literature. Clinically focused databases included were PubMed/MEDLINE and CINAHL. PubMed/MEDLINE was chosen over other medical databases because of its update frequency and inclusion of early online articles, as well as its focus on medicine [20], while CINAHL adds to the search an emphasis on the perspectives of nursing and allied health disciplines. In addition, searches were conducted in ProQuest’s Sociological Abstracts and EBSCO’s EconLit and Academic Search Premier. Database selection was designed to provide as broad a range of coverage as possible, including the medical, economic, and social science literature. Test searches were conducted and were used to develop lists of search terms tailored to each database. These search term lists included MeSH terms, other database-specific subject terms, and other term combinations agreed upon by the study team based on the selection criteria. Every effort was made to maintain consistency in the search terms; however, some variations proved necessary in order to properly adapt our objectives to the differing controlled vocabularies used across these heterogeneous subject databases in order to obtain specific and relevant search results. Final searches were conducted throughout June 2023. For details of search strings adapted to individual databases and associated results, see Table 1.

2.2. Study Selection

As described above, we systematically searched the following electronic databases: PubMed/MEDLINE, CINAHL, Sociological Abstracts, EconLit, and Academic Search Premier. Searches took place in June 2023. In addition to database searches, the team performed hand searches of select literature reviews as well as related article searches using relevant database tools. Study selection was performed following PRISMA-ScR guidelines.
We included primary studies that met the following criteria:
  • Included adults with limited English proficiency as a clearly defined subset of the study population. We defined adults as subjects over the age of 18.
  • Included LEP subjects residing in the United States. We excluded studies not conducted in the United States, as policies and laws that govern language services as well as access to care may be different across English-speaking countries.
  • Study outcomes were quantitative and related to healthcare service access (e.g., health screenings, ambulatory care, hospital care, or mental health) or to clearly defined health outcomes, including outcomes related to healthcare costs.
  • Quantitative health care outcomes were specified for LEP populations based on spoken language. As noted in our objectives, electronic medical records typically contain only information regarding the primary language spoken. In order to isolate the effects of spoken language from those of literacy, we focused on studies that had outcomes based on spoken language only or clearly defined a subset of results based on spoken English ability.
We excluded studies for the following reasons:
  • Because our objective was to focus on spoken language proficiency among immigrant populations that have a primary language other than English, we excluded any studies primarily focused on a deaf or hard-of-hearing population. Although this is an important topic, the research team felt that it would require a separate and focused review.
  • We excluded studies with outcomes focused on access to particular drugs or types of drugs (such as opiate pain medications). Studies that assessed specific interventions were also excluded. Studies with only qualitative outcomes were excluded from the analysis.
  • Studies published prior to 2000 were excluded by database filters due to changes in policy around medical records data collection and language accessibility. Our searches included dissertations and theses. However, we elected to exclude conference presentations, posters, and preprints. We excluded studies written in languages other than English and studies not primarily focused on adults, defined as subjects ages 18 and older.
  • Studies were excluded if healthcare outcomes were not specified for the LEP population, if the LEP definition was not clearly based only on spoken language, or if outcomes were not available for spoken language only.
Following database searches, all identified citations were collated and uploaded into Zotero, and duplicates were removed. Our review team then conducted pilot testing with 20% of the abstracts to assess inter-reviewer agreement on inclusion/exclusion criteria. We assessed inter-reviewer agreement in the pilot screening based on percent agreement in order to ensure that the inclusion and exclusion criteria were clear and applied consistently. Based on the high percent agreement (94.5%) in the pilot screening, all abstracts were screened using the inclusion and exclusion criteria provided above by members of our review team, and a process of consensus was used for any exclusions. Any abstract exclusions were agreed upon by at least two team members. The remaining potentially relevant sources were retrieved in full-text form and assessed in detail against the inclusion criteria by members of the study team. Reasons for the exclusion of full-text studies that did not meet the inclusion criteria were recorded. All exclusions at the full-text stage were discussed and agreed upon by at least three members of the review team, including the PI. Any disagreements that arose at each stage of the selection process were resolved through full team discussion. For further details of the search flow, please see Figure 1 below.

2.3. Data Extraction

For each study, we extracted the following data points: Primary health-related outcome; study design; study period (years); study setting or context; how the LEP population was defined for the study; both the total sample size and the LEP sample size; languages spoken by participants (if recorded); results related to the LEP sample studied and associated effect sizes; bibliographic information. Because secondary data that identifies immigrant populations is difficult to find, the team additionally identified any secondary datasets that were specified as part of the research. While generally scoping reviews do not include a critical appraisal of the sources of evidence, we made broad determinations of study quality based on objective study characteristics, including sample size, research methodology, and generalizability of the study, in order to add context to the study outcomes. During data extraction, the studies were categorized by major outcomes, which included ambulatory care outcomes, hospitalization outcomes, screening outcomes (that is, studies looking at screening initiation and access to screening tests), specific condition outcomes, and general physical and mental health outcomes. If a research study had outcomes that fit into more than one category, the study and specific outcomes that fit the outcome category were included in each applicable category, so that studies that addressed more than one outcome category could be included multiple times in the results section.

3. Results

After review, 137 studies met the inclusion criteria. Table 2 provides an overview of publicly available secondary datasets that were used for various studies, listing outcome categories, in order to allow researchers interested in LEP and healthcare to more easily identify data that can be used to understand this at-risk population. Major themes of the results by outcome category are summarized below, and Table 3, Table 4, Table 5, Table 6 and Table 7 provide specific data on study methodology, sample size, linguistic groups, and study outcomes.

3.1. Ambulatory Care Studies

There were 29 studies looking at the influence of LEP on ambulatory care outcomes that met our inclusion criteria after review [2,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48]. A majority of studies had a cross-sectional design, and many used large national datasets to conduct analysis, such as the National Health Interview Survey and the Medical Expenditure Panel Survey. A regional survey that was frequently utilized was the California Health Interview Survey. The two main ethnicities researched were Asian and Hispanic populations, and this is likely the reason why those studies that identified languages spoken by LEP participants included mostly Spanish and Asian languages. However, many studies did not specify languages spoken, only participant ethnicities. All of the studies in this group were low to moderate in terms of quality due to small sample sizes that may not be representative of the population, unclear or potentially inaccurate definitions of LEP, and the general lack of data on LEP populations due to a greater focus on acculturation, ethnicities, and/or literacy. This resulted in a scarcity of LEP-specific ambulatory outcome data in many of the included studies.
The majority of the ambulatory care studies looked at healthcare utilization and access. These studies found that LEP patients were significantly less likely than their English-proficient (EP) counterparts to have a regular source of care and that EP individuals had a greater number of physician visits compared to LEP individuals [2,21,23,26,27,28,33,36,38,39,41,42,43,44,47]. Most studies found that LEP individuals were more likely to forgo necessary medical care, less likely to receive preventive care, less likely to have a usual source of care, and even, in one case, showed an increase in missed preventive care visits [36] compared to EP populations. Two studies, Njeru et al. and Pylypchuk et al., found mixed results on access to care. Njeru et al. looked at adherence to telephone line triage recommendations for healthcare and found that LEP patients were less likely to follow through with recommendations to call an ambulance, visit the emergency room, and recommend home care, but more likely to follow through with a routine visit within a week compared to the EP population [49]. Pylypchuk et al. found a mix of outcomes looking at preventive care for LEP immigrants compared to their native counterparts depending on insurance type. The analysis showed that LEP immigrants with private insurance were less likely to have their flu shot, have their cholesterol checked, go to the dentist, and have a breast exam in the past year, but there was no difference in medical visits. However, for individuals who had public insurance or were uninsured, there were no significant differences in preventive care between LEP immigrant and native populations [30]. There were two studies in this category that either did not find a significant difference between LEP and EP populations in their ability to access ambulatory care [31] or that LEP populations had higher rates of seeing a primary care physician and/or specialty care physician compared to EP populations [37]. This study also found that LEP populations had lower rates of emergency room visits. Because of the differences in ambulatory care utilization found by the majority of studies, Himmelstein et al. found that Hispanic LEP individuals spend USD 1463 less overall on medical care compared to their Hispanic EP counterparts and USD 2802 less than non-Hispanic EP individuals [39]. Jacobs et al. found that the use of interpreter services increased the number of clinical (ex: office and urgent care visits, phone calls, and prescriptions) and preventive services (ex: mammograms, fecal occult blood testing, rectal exams, and flu vaccinations) received among LEP patients [40]. This indicates that changes to service provision could ameliorate differences in access and outcomes for LEP patients.
There were three ambulatory care studies that specifically looked at mental health services [22,25,33]. For all three studies, having LEP significantly reduced the likelihood of utilizing mental health services for some or all of the populations studied. The studies focused on Hispanic only [33] or Hispanic and Asian [22,25] populations. Bauer et al. found that both Hispanic and Asian LEP populations were less likely to access mental health services over their lifetimes and spent more time living with untreated mental illness compared to the EP population. Meanwhile, Kim et al. looked specifically at immigrant populations with psychiatric disorders and found that LEP significantly affected mental health service use for the Hispanic population but had no statistically significant effect on the Asian population with psychiatric disorders. Two of the three mental health studies had small sample sizes, and all three studies were cross-sectional.
The rest of the included studies investigated different specific aspects of ambulatory care. One study looked at the likelihood of LEP individuals completing an advanced directive and found that the probability of advanced directive completion among Hispanic LEP individuals was much lower than their EP counterparts. It was also found that living in a Spanish-speaking community was a negative predictor of advanced directive completion [34]. Another study looked at cardiovascular risk reduction outcomes in a pharmacist-managed clinic and found no significant difference between LEP and EP groups but had a very small sample size for LEP (n = 9) [35]. Studying a refugee population, Geltman et al. found significantly lower rates of both overall dental care and specifically preventive visits for LEP refugees compared to their EP counterparts [48]. Another study looked at medication management in home healthcare and found that LEP patients showed less improvement in both oral and injectable medication management with home healthcare [45]. Even when looking at specific ambulatory care services rather than general access and outcomes, the majority of studies found that service use, process of care, and outcomes showed significant disparities between LEP and EP populations. Please see a list of studies included in this category with key summary information in Table 3 below.
Table 3. Ambulatory Care Study Details.
Table 3. Ambulatory Care Study Details.
Ambulatory Care
Study DesignStudy PeriodSample Size
LEP Sample Size (n=)SettingLEP DefinitionLanguagesStudy Outcomes (LEP Related)
[25]mental health service usecross-sectional2002–20031147465United Statespoor/fair English speaking abilitySpanish, Mandarin, Cantonese, Vietnamese, and TagalongSignificantly fewer LEP individuals for both Latino and Asian populations (compared to EP individuals) accessed lifetime mental health services (42.8% vs. 54.2%, p = 0.01, 32.9% vs. 53.9%, p = 0.01). LEP individuals for both Latino (14.6 vs. 9.4 years, p = 0.01) and Asian populations (16.3 vs. 9.0 years, p = 0.001) live longer with their disorder untreated. The EP population had a significantly higher odds of lifetime treatment for their mental health, with EP Latinos and Asians (OR 1.7; OR 2.3) significantly more likely to receive treatment compared to LEP individuals.
[26]usual source of carecross-sectional20052740NACaliforniareported speaking English less than ‘‘well.’’NA44.7% of LEP participants had a usual source of care other than the ER, significantly less than their EP counterparts (p < 0.01).
[31]healthcare accesscross-sectional2011–20195032NAGreater Los Angeles areaEnglish speaking ability was described as not well or not at allNANo significant interaction between English proficiency and regular doctor access.
[33]health care utilization (mental and physical health)cross-sectional1996–199731,0031652United Stateslanguage of surveySpanishFor LEP Hispanic participants, 61% had a physician visit in the past year and 4.0% had a mental health visit in the past year. LEP Hispanic patients were significantly less likely than non-Hispanic White patients to have had a physician visit (RR, 0.77; CI, 0.72–0.83) and a mental health visit (RR, 0.50; CI, 0.32–0.76).
[48]dental carecross-sectional2009439247MassachusettsThose who score no/low on the BEST Plus testNADental visit rates in the last year for LEP refugees were 48.6%, significantly lower than EP (p = 0.04). In the last year, 27.4% of LEP refugees had a preventative dental visit, significantly lower than EP (p < 0.01).
[34]advanced care planningcross-sectional2013–2017620,94815,656Northern
California integrated health system
Needing an interpreterSpanishAdvanced directive (AD) completion probability was much lower among Hispanic Spanish speakers compared to their English-speaking and White counterparts. Negative predictors of AD completion included living in a primarily Spanish- speaking community (living in a census tract where >35% of residents were Spanish speakers, OR = 0.9; 95% CI= 0.8–0.9).
[35]cardiovascular risk outcomesretrospective cohort study2010–2012719Wishard Health
Services & Eskenazi Health Indianapolis, IN
only speak SpanishSpanishThere was no significant difference found in outcomes between the English speaking and Spanish speaking groups.
[37]health service utilizationcross-sectional20001703565WashingtonUsed interpreter service at least onceSpanish and otherA higher proportion of LEP patients visited primary care (95% versus 82%) and specialty care (60% versus 50%), but a lower proportion visited the emergency room (31% versus 47%). Annualized numbers of visits to primary care sites were 6.2 per year for LEP subjects compared to 3.8 for English speakers. Specialty visits were 2.9 per year for LEP subjects compared to 2.2 for English speakers.
[38]usual source of care and healthcare utilizationcross-sectional201821,1771730CaliforniaParticipants who
reported speaking English not well or not at all
Spanish, Cantonese,
Mandarin, Korean, Tagalog, and Vietnamese
LEP individuals were significantly less likely than their EP counterparts to have a usual source of care other than the ER, have a usual place to go when sick or needing medical advice, have preventative care in the last year, delay not getting medical care in the past 12 months, and forgo necessary care (p < 0.01).
[39]health care spending and utilizationcross-sectional1998–2018120,54617,776United Statesif their interview was conducted in SpanishSpanishLEP Hispanics spent $1463 less on medical expenses on average compared to their EP Hispanic counterparts (p < 0.001). LEP Hispanic individuals spent $2802 less on medical expenses on average compared to EP non-Hispanic individuals (p < 0.001). LEP Hispanics spent $456 less on outpatient care on average compared to their EP Hispanic counterparts (p < 0.001). LEP Hispanic individuals spent $708 less on outpatient care on average compared to EP non-Hispanic individuals (p < 0.001). LEP individuals were significantly less likely to utilize outpatient visits compared to their non-Hispanic and Hispanic EP counterparts (p < 0.001).
[41]healthcare utilizationcross-sectional2006–20072884NAUnited StatesEnglish proficiency
below moderate (read at least a little or somewhat)
NA37.25% of those who were classified as LEP had used healthcare in the last 2 years compared to their proficient (81.20%) and moderately proficient (64.53%) counterparts (p < 0.001).
[42]usual source of carecross-sectional2014342286CaliforniaParticipants who
reported speaking English less
than ‘very well’
Korean and otherParticipants with LEP were 8.13 times more likely to not have no usual source of care (CI 2.40–27.56, p < 0.01).
[40]delivery of healthcare & receipt of clinical and preventative health servicesretrospective cohort study1995–19974380327four HMOs in New EnglandUse of interpreter servicesSpanish & PortugueseThere was a significant increase in nearly all clinical service usage (office visits, phone calls, urgent care visits, prescriptions written, and prescriptions filled) in the interpreter services group after the updated interpreter services were implemented. For example, there was a greater increase in the number of prescriptions filled by those in the interpreter services group (2.33 prescriptions per person) compared to those in the comparison group (0.86).
For preventative services receipt (mammograms, breast exams, pap smears, fecal occult blood (FOB) testing, rectal exams, and flu vaccinations), the increase in receipt of these services in the control group ranged from 0.01–0.10. In contrast, the increase for the interpreter services group ranged from 0.01–0.26. There were significant increases in the number of rectal exams for men over 40 years old. However, this difference was not significant after adjusting for
demographic differences between the groups.
[43]usual source of carecross-sectional201525941618Austin, TexasReported that they spoke English less than very wellNAAfter controlling for covariates, the risk of having no usual place for care was 2.09 (42.2% vs. 31.4%) times higher among the LEP population (p< 0.001). The risk of having no regular check-up was 1.69 (35.6% vs. 27%) times as great (p < 0.001). Perceived unmet needs for medical care were 1.89 (14.6% vs. 6.4%) times as great (p < 0.001). Reported communication problems in healthcare settings were 4.95 (42.1% vs. 6.9%) times as great ( p < 0.001).
[36]missed primary care appointmentscross-sectional2015–2018159,05442,030Hospitals in BostonPreferred language of care was other than EnglishSpanish, Portuguese, and Haitian CreoleAt baseline, the proportion of missed appointments was 19.4% among Spanish, Portuguese, and Haitian Creole speakers compared to 20.4% of English speakers. The prevalence of missed appointments increased by 0.74 percentage points (CI: 0.34, 1.15) among Spanish, Portuguese, and Haitian Creole speakers compared to English speakers over the same time period. This amounted to 799 additional missed appointments in the post-period than expected.
[44]health care utilizationcross-sectional2005–2007217NAArizonalow English speaking, writing, and reading skillsNAIncreased EP scores revealed a 6% increase in physician visits (p < 0.05).
[22]mental health service usecross-sectional2002–2003372234United StatesFair/poor English speaking abilitySpanish, Vietnamese, Mandarin, Cantonese, andFor adult Latino immigrants with psychiatric disorders, having LEP significantly decreased the odds of using mental health services (OR = 0.30; CI = 0.14, 0.64) compared to all immigrants with psychiatric disorders. In the Asian immigrant population with psychiatric disorders, LEP did not significantly affect mental health service use.
[21]healthcare utilizationcross-sectional20071745988CaliforniaEnglish speaking ability was not well or not at allSpanish, Korean,
Mandarin, Vietnamese, and Cantonese
Among Asians, LEP individuals were less likely (p < 0.001) than EP and English only individuals to see a medical doctor
in the past 12 months. Among Asian LEP population who had seen a doctor, the total number of doctor visits was significantly higher (5.73) than for EP (3.92) and English only (2.85). Group differences were not significant in the Latino population.
[23]healthcare accesscohort cross- sectional2006–2016190,69816,484United States(a) reported that
a language other than English was spoken in their home or (b) reported that they did not speak English well or that they were not comfortable speaking English.
NAThe proportion of individuals with LEP who had a usual source of care before the ACA was 45.3% and after the ACA was 53.1% which was a significant improvement (p < 0.001). Compared to their LEP counterparts, EP individuals had a 4.9% higher chance of having a usual source of care (p < 0.001). The proportion of individuals with LEP who had to forgo any necessary care was reduced from 10.3% before the ACA to 7.1% after the ACA, a −3.5% difference.
Compared to their LEP counterparts, EP individuals were 3.2% less likely to forgo any necessary care (p < 0.001). The proportion of individuals with LEP who had to forgo any necessary medical care was reduced from 4.8% to 2.8%, a −2.2% difference (p < 0.001). Compared to their LEP counterparts, EP individuals were 1.4% less likely to forgo necessary medical care. The proportion of individuals with LEP who had to forgo any necessary dental care was 7.5% before the ACA to 5.2% after the ACA, a −2.4% difference (p < 0.001).
[24]dental carecross-sectional2013–2014 2114United Statesself-reported as “limited”NAWhen accounting for acculturation factors, LEP was a significant factor for having a dental visit in the previous 12 months (p < 0.05). However, after considering dental insurance and income, the LEP variable became insignificant (p= 0.18).
[45]medication management with home healthcareretrospective matched case- control2010–201473,815 for oral; 7807 for injectable17,662 fororal; 2248 for injectablenonprofit home health agencyNANALEP was associated with less improvement in oral MM (.049, CI [.032-.065]) and injectable medications (.078, CI [.023-.133]) when compared to English-speaking patients.
[46]eye carecross-sectional2000–200354552775La Puenta, CaliforniaPreferring Spanish/Speaking only Spanish at homeSpanishFor participants who only spoke Spanish at home, the odds ratio for one or more eye care visits in the last 12 months was 0.79 (p < 0.05) compared to those who spoke English or both languages at home. There was no significant difference for having a dilated eye exam and having one or more dilated eye exams in the past 12 months.
[47]usual source of carecross-sectional2003 and 200530111207CaliforniaEnglish speaking described as not well or not at allN/A10% of those with LEP had no usual source of care (p < 0.001, OR = 2.3).
[32]following recommendations for healthcare visitretrospective cohort study (chart review)2012–20131174587Minnesota primary care practiceusing an interpreter for the phone lineSomali, Asian languages -including Vietnamese, Cambodian andLEP callers were less likely to follow the nurse’s recommendation than non-LEP callers (AOR, 0.65; p < 0.001). Stratified by recommended action LEP patients were less likely to follow through with recommendations to call an ambulance or visit the ED (AOR, 0.28; CI, 0.13, 0.60) and recommended home care (AOR, 0.34; CI, 0.22, 0.55), but more likely for follow through with a routine visit within a week (AOR, 2.45; 95% CI, 1.24, 4.82).
[2]usual source of care, delays in getting carecross-sectional200118,0001242CaliforniaIndividual reported speaking English not well or not at allSpanish, Cantonese,
Korean, Vietnamese, and Khmer,
In bivariate analysis LEP older adults had significantly higher proportions that lacked a usual source of care than older adults who speak English only. In multivariate analysis, LEP older adults had increased risk of not having a usual source of care (RR = 1.86, p = 0.033) compared with English only speakers, but no significant differences in delays in care.
[30]preventative care utilizationcross-sectional2000–2004NANAUnited StatesIf respondent answered survey in another language besides EnglishNALEP immigrant population with private insurance was significantly less likely to get their flu shot, have their cholesterol checked, go to the dentist, and get a breast exam in the past year compared to the native population. There was no significant difference found for primary care visits, mammograms, or prostate exams between LEP immigrant population and native population with private insurance. There were no significant differences found in preventive care between immigrants with LEP and native populations with pubic insurance or who were uninsured.
[29]primary care utilizationcross-sectionalNA275102TennesseeSpeaks English a little or not at allNAThere was no significant difference in LEP and EP individuals in visiting their primary care provider regularly (p =0.057).
[27]delayed medical care, forgone needed care, and visits to healthcare professionalcross-sectional200629,8682606United StatesSpeaks English less than very wellSpanish and other languagesCompared to English-proficient individuals, more individuals with LEP had forgone care (p < 0.05) and fewer reported healthcare visits (p < 0.001). Through unadjusted analyses, the study found that LEP individuals had 18% higher odds of forgoing medical care and 58% lower odds of having a healthcare visit compared to English-proficient individuals. In adjusted analyses, LEP individuals had 34% lower odds of having a healthcare visit.
[28]healthcare utilizationcross-sectional200049,327NACalifornia, Colorado, Hawaii, Kansas, Michigan, New York, Ohio,Survey language and language spoken at home were SpanishSpanish and otherFor participants who were Hispanic-Spanish and Asian-Other, there were significantly lower reports of timeliness of care, provider communication, and staff helpfulness (HS: −11.470, −3.575, −5.502, AO: −12.649, −7.158, −10.270; p < 0.001). There was also a significant difference in getting the care needed among Asian-Other participants(−8.459; p < 0.001).
NA means not available in the published manuscript. Abbreviations used in the table include the following: LEP, limited English proficiency; EP, English proficient.

3.2. Hospital Care Studies

There were 31 studies investigating limited English proficiency within hospital care settings that met our inclusion criteria [7,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78]. More than half (18 in total) were retrospective cohort studies, the next most common being cross-sectional studies (seven in total). These hospital care studies addressed a variety of elements related to hospital care, such as end-of-life and palliative care, healthcare service delivery and patient satisfaction, interpreter impact, potentially preventable conditions, discharge instructions, length of stay, and hospital stay cost. Eight studies were conducted using data from California public hospitals or healthcare systems [50,51,52,53,54,55,56,57]. State and national datasets used in hospital care studies included the National Trauma Registry of the American College of Surgeons (NTRACS), the Agency for Healthcare Research and Quality’s (AHRQ) Healthcare Cost and Utilization Project (HCUP), California State Inpatient Databases, the American Hospital Association’s (AHA) Annual Survey, Hawaii’s Health Information Corporation’s (HHIC) inpatient database, and the Asian American Elders in New York City Study (AAENYC). The majority of the hospital care studies were considered moderate in terms of quality, primarily due to small LEP sample sizes, deficient LEP definitions, a lack of diversity in languages studied, and limited study locations. The most commonly studied language populations included Spanish, Cantonese, Mandarin, Portuguese, Arabic, and Russian, though this varied depending on location or dataset usage. A study by Sentell, Chang, Ahn, and Miyamura using the HHIC examined birth outcomes among a diverse range of Asian and Pacific Islander languages, such as Micronesian, Tagalong, Ilocan, Visayan, Chuukese, Marshallese, Tongan, and Samoan [58]. One study by Hines et al. using HCUP investigated inpatient mortality rates and obstetric trauma among 20+ languages [40]. There were five hospital care studies that did not specify languages and used a broad LEP categorization. These five studies examined emergency department outcomes and readmissions [59,60], unintentional adverse events [7], opioid discharge pain management in trauma patients [57], and emergency medical services scene and transport times [61].
A key area of interest among the hospital care studies was length of stay (LOS) and readmissions. In some studies, LOS was significantly greater for LEP populations, such as palliative care patients [62] and those who underwent a total joint arthroplasty [63]. In one study, LEP status was significantly associated with an overall increased hospital LOS for traumatic injuries when compared to EP status, though intensive care unit (ICU) LOS was shorter among LEP patients [50]. Increased LOS patterns for LEP patients were not found in studies looking at non-trauma-related hospital stays [53,64]. The impact of interpreter usage on LOS was inconsistent across hospital departments. While two studies found that use of interpreter services decreased in-hospital LOS [65,66], Wallbrecht et al. found that LOS from time of arrival to discharge in an emergency department (ED) increased when interpreters were used [67]. Studies exploring hospital admission and readmission had more consistent findings. Six studies found that LEP patients were more likely to be admitted upon visiting the emergency department or to be readmitted within 30 days [49,56,59,60,68,69,70], and another study determined that interpreter usage minimized the likelihood of 30-day readmission [65].
Another area of interest in hospital care studies was post-discharge understanding of care. Studies showed that EP patients tended to be prescribed more medications at discharge [57,71], specifically more opioids, and the level of post-discharge understanding of care was consistently lower among patients with LEP compared to EP. LEP patients were often unaware of their prescribed medications’ purpose and required more assistance with filling their prescriptions [71,72], though another study highlighted that understanding increased with interpreter assistance [73]. Despite having an initial lower level of post-discharge understanding, one study found that LEP patients asked more questions regarding their treatment, even without an interpreter, when compared to EP patients. This was particularly true for Spanish-speaking patients, who asked more clinical questions and reported issues with their discharge instructions more frequently in comparison to other LEP patients [72].
There were four hospital care studies that investigated the impact of LEP status on gynecological and obstetrics service delivery and outcomes. While one study found that LEP status was associated with an increased risk of having a primary cesarean delivery, particularly among those with diabetes [58], Hessol et al. found that LEP was significantly associated with lower rates of cesarean delivery compared to the EP population in one of the hospitals investigated but found no significant difference in outcomes at the other hospital in the study [51]. Hines et al. found that Spanish speakers and those who spoke Asian-Pacific Islander languages showed higher obstetric trauma rates when compared to EP patients [52]. LEP status could be a barrier for gynecological and obstetric Spanish-speaking patients who require pain medication if interpreter services are not always available. LEP patients who rarely received interpreter services during their hospitalization reported that healthcare professionals did not provide sufficient pain control, did not respond to patient needs in a timely manner, and were overall unhelpful when compared to LEP patients who always had consistent access to interpreter services during their stay [74]. This speaks to the contextual nature of LEP barriers to obstetric care, with adequate interpreter services potentially providing an ameliorating effect on outcome disparities.
The remaining hospital care studies primarily focused on healthcare service delivery and outcomes, as well as patient satisfaction. Several of these studies continued to examine the impact of interpreter services. In one study, English speakers tended to be more satisfied with their triage experiences, while Spanish speakers felt as if nurses did not understand their medical complaints [75]. In a different study, English-speaking patients received more tests and medical procedures than their LEP counterparts [76], though another study found that LEP patients were more likely to have electrocardiograms (ECG) performed by emergency medical services and within emergency departments [61]. Divi et al. conducted a study within six Joint-Commission-accredited U.S. hospitals showing that LEP patients experienced more unintentional adverse health events that resulted in physical harm not attributed to their initial condition or diagnosis compared to EP patients [79]. Finally, though LEP status was not associated with differences in advanced care planning discussions in hospitals [54], it was shown to impact informed consent. EP patients were more aware of informed consent, and interpreter services enhanced informed consent knowledge among LEP patients [55,77]. Differences in outcomes by hospital department, specifically differences across inpatient and ED settings, were shown consistently across multiple hospital-focused studies, indicating that LEP may impact care differently depending on the context. Importantly, significant disparities driven by LEP were identified in terms of processes such as informed consent and outcomes such as adverse health events. Please see a list of studies included in this category with key summary information in Table 4 below.
Table 4. Hospital Care Study Details.
Table 4. Hospital Care Study Details.
Hospital Care CitationsHealth
Study DesignStudy PeriodTotal Sample Size
LEP Sample Size (n=)SettingLEP DefinitionLanguagesStudy Outcomes (LEP Related)
[68]end-of-life and palliative careretrospective cohort2010–201818,4901363Washington“In what language do you want to talk to your healthcare team about your care?”Mandarin Cantonese Vietnamese Russian SpanishIn adjusted analyses, LEP patients had higher odds of ED visits in the last 30 days (OR 1.47; CI 1.26, 1.72) & 180 days of life (OR 1.36; CI 1.17, 1.57). LEP patients had higher odds of 30-day readmission within the last 90-days (12% vs. 7.6%; OR 1.64, CI 1.30, 2.07) & 180-days of life (14.1% vs. 9.6%; OR 1.44; CI 1.16, 1.71) & higher odds of having an in-hospital death (OR 1.24; CI 1.07, 1.44). LEP patients had lower odds of advance care planning documents prior to death (OR 0.68; CI 0.59–0.80) when compared to EP patients.
[75]door-to-room time and patient satisfactionprospective cohort2011–201316355Level 1 trauma center with an EDPatients rated their language skillsSpanishThe median door-to-room and likelihood of admission was not significantly different between English-speakers and Spanish-speakers. English-speakers generally felt that the nurses completely understood their medical complaints, scoring a median of 5 on a 5 point Likert scale. Spanish speakers felt nurses mostly understood their medical complaint, scoring a median of 4 on a 5 points, and this comparison was statistically different between the groups. Spanish- speaking patients were significantly less satisfied with their triage experience than English-speaking patients. Of patients who described themselves English speakers, nurses misclassified one patient as having LEP. Of the patients who described themselves as Spanish speakers, nurses misclassified 15 as English speakers.
[78]Potentially preventable intubationsretrospective cohort1994–200327421Level 1 trauma center in eastern North CarolinaPatient’s primary languageSpanish21 Spanish-speaking patients were intubated for less than 48 hours, compared to the 38% English-speaking patients.
Spanish-speaking patients had less serious injuries as per the Injury Severity Score (ISS) compared to the English speaking group (10.5 vs. 13.0). The Spanish speaking group had greater Glasgow Coma Score (GCS) than English- speaking patients.
[62]code status, advance directives, limiting life support decisionsretrospective cohort2011–201427,523779Seven ICUs of
varying specialties in a single center
Primary language or interpreter use as noted on medical chartArabic, Spanish,
Somali, Cambodian, Vietnamese, Lao, Hmong, Russian,
After adjusting for illness severity, sex, education, & insurance status, patients with LEP were less likely to change their
code status from full code to do not resuscitate (DNR) during ICU admission (OR, 0.62; p < 0.001)
People with LEP who died in the ICU were less likely to receive a comfort measures order set (OR, 0.38; p = 0.03).
[76]healthcare service
delivery for initial ED visit and following 90 days
retrospective cohort1999500437urban academic teaching hospitalSelf-reported primary
language and if the patient is comfortable communicating in English
Spanish, Haitian Creole, and Portuguese CreoleEnglish-speaking patients spent more hours (mean = 11.83 h, 95% CI 9.59–14.08) than LEP patients who did not
receive interpreter services (8.62 hours, 95% CI 7.68–9.61) and LEP patients who did receive interpreter services (9.51 hours, 95% CI 7.10–11.92). English-speaking patients also had the highest post index visit ED cost (USD 988) when compared to the those who received interpreting services (USD 878) and those who did not (USD 710). English-speaking patients had more test and procedures done (mean = 13.40) than those who received interpreting services (12.69) and LEP patients who did not receive interpreting services (10.58). More English-speaking patients returned to the ED within 30 days of discharge (mean = 8724) than LEP patients who received interpretation services (7584) and those who did not receive interpreter services (5305).
[50]morbidity and mortality after traumatic injuryretrospective cohort study2012–201813,1042144Zuckerberg San
Francisco General Hospital (ZSFG), an
English was not among patient self-reported languages spokenChinese, Spanish, and OtherLEP patients had an increased rate of TBI when compared to EP patients (41% versus 38%). In multivariate analyses,
LEP patients were significantly associated with increased hospital LOS, decreased ICU LOS, decreased transfer to acute care hospital, and increased discharge home with home health services or skilled nursing facility (SNF)/rehabilitation.
[69]healthcare utilization, end-of-life and palliative care for COVID-19 patientsretrospective cohort202033789Two academic & four community hospitals in BostonSelf-reported primary language other than English listed in the EHRCreole, Russian, Portuguese, Italian, Cantonese, Vietnamese, Portuguese Creole, Khmer, French,More LEP patients died in the ICU than EP patients (61.8% vs. 35.1%). More LEP patients received CPR when compared to EP patients (10.1% vs. 3.6%). Patients with LEP were admitted or transferred to the ICU more often than EP patients (82.0% vs. 52.8%). LEP was not associated with delayed palliative care consultations. LEP patients more often received mechanical ventilation or ECMO than EP patients (82.2% vs. 61.8%), but time spent on mechanical ventilation or ECMO did not differ. LEP was associated with a longer hospital LOS (mean difference 4.12 days; 95% CI 1.72–6.53). However, LEP was not associated with ICU LOS.
[66]peri-operative LOScross-sectional2018574NAAcademic medical center in Bostonusing interpreting servicesSpanish, Portuguese, Chinese, Arabic, and OtherIn unadjusted analyses, the median LOS decreased with increased number of interpreting events per day. Patients in Quartile 4, who had 3+ interpreting events per day, had a median LOS of 1 day. Patients in Quartile 1, who had less than one interpreting event per day, had a median LOS of 11 days. There was an association between greater frequency of interpreting events and shorter surgical patient’s peri-operative LOS.
[7]instances of unintended harm to the patients not relating to their disease or
prospective cohort20051083251Six Joint Commission accredited hospitals in the
Non-English speakingNA49.1% of reported adverse events (defined as any unintended harm to the patient not due to their underlying disease or condition) in LEP patients caused physical harm. A greater proportion of LEP patient adverse events resulted in a higher level of harm. LEP patients experienced more adverse events due to communication failure when compared to EP patients (52.4% vs. 35.9%). LEP patients experienced more adverse effects due to practitioner factors than EP
patients (21.9% vs. 17.2%).
[51]interpersonal processes of care (IPC) and cesarean deliverycross-sectional study2004–20061308NAKaiser
Permanente Medical Center and San
Poor or no English proficient based on interviewSpanishAt KP-MC, women who reported good or fluent English proficiency were more likely to deliver via cesarean than women with poor or no English proficiency (OR = 0.04, 95% CI 0.005–0.33). However, at SFGH, women with poor or no English proficiency were more likely to delivery via cesarean (OR = 1.61, 95% CI 0.86–3.05).
[52]Inpatient mortality rates & obstetric traumacross-sectional20093,211,457545,762Community, non-
rehabilitative hospitals in California
Patient’s self-reported principal languageSpanish & Asian-
Pacific Islander languages (Chinese, Japanese,
The risk-adjusted inpatient mortality for congestive heart failure, strokes, and pneumonia among Spanish and API
language speakers were similar to or somewhat lower than that of EP patients. Age-adjusted rates of obstetric trauma were lower among Spanish speakers and higher among API language-speakers when compared to EP patients.
[74]quality of acute pain
treatment for obstetric and gynecological care patients
cross-sectional2003 & 2006185NAtwo teaching hospitalspatients who reported a need for interpreter serviceSpanishThe group who responded as “Not Always” receiving interpreter services reported significantly lower scores for pain
control (OR = 0.4, 95% CI 0.2–0.8), timely response (OR = 0.4, 95% CI 0.2–0.8), and perceived helpfulness from staff to respond to pain (OR = 0.3, 95% CI 0.2–0.7) than those who reported “Always” using interpreter services. Language barriers were reported by 13% of patients in the “Not Always” group as an obstacle to obtaining pain medication compared to the 8% in the “Always” group.
[71]understanding discharge instructionsCross-sectional2005–2008308203Urban public
hospital’s general medical-surgical floor
Asking patients “How well do you speak English? and “In what language do you prefer to receive medical care?” Spanish & ChineseLEP participants had fewer discharge medications than EP participants (3.6 vs. 4.6). LEP patients were less likely than
EP patients to have post-discharge ED visits or re-hospitalization (9% vs. 27%). Models were adjusted for clinical site, data collection time-period, and discharge time. LEP status was associated with lower odds of understanding medication category (OR = 0.63) and the outcome of medication category and purpose (OR = 0.89). LEP patients who reported language concordant discharge instructions had lower odds of understanding than EP patients (OR = 0.39).
[53]hospital costs, LOS,
30-day readmission, and 30-day mortality risk.
observational cohort2001–200358771146General Medicine
Service at the University of California, San
language codes collected from patient registration databasesChinese (Cantonese or Mandarin), Spanish, RussianSpanish and Russian-speaking patients had lower 30-day readmission rates (2.5% and 6.4%, respectively) than the EP
group and the Chinese-speaking group. Chinese-speaking patients had the highest 30-day mortality (OR = 1.0, 95% CI 0.8–1.4). LEP patients had a higher odds of readmission at 30-days post-discharge than the EP group (OR = 1.3; 95% CI 1.0–1.7).
[64]30-day readmission, LOS, & hospital expendituresnatural experiment2007–201080771963Academic medical centerPatient’s primary language entered at registration Chinese, Russian, Spanish, other Asian language, and OtherLEP patients all received the intervention (Bedside Interpreter Intervention). The odds of 30-day readmission for the
LEP group compared to the EP group was lower during the intervention period (0.64; 95% CI 0.43–0.95) than it was during the pre- & post-intervention periods (1.07; 95% CI 0.85–1.35 & 1.09, 95% CI 0.80–1.48 respectively).
[54]advance care planning discussions prevalencecross-sectional2005–2008369232medical and
surgical wards of two large urban hospitals in the
If patients answered “not at
all”, “not well” to the question “How well do you speak English?”
Spanish & ChineseParticipants’ English proficiency was not associated with report of advance care planning discussions.
[73]hospital dischargeprospective cohort2012–20139479cardiovascular,
general surgery and orthopedic surgery floors in
Speaking English not at all or not wellSpanish, Cantonese, & MandarinPre-post discharge preparedness and patient-reported knowledge of follow-up appointments, discharge medication
administration and side effects did not differ significantly after the implementation of the bedside phone interpreters. However, in bivariate models, knowledge of medication purpose increased significantly from before compared to after the implementation (88% vs. 97%).
[77]informed consentprospective cohort2012 & 2013152NAAcademic medical centerHospital identification algorithmSpanish, Cantonese, MandarinResearchers evaluated the impact of a bedside interpreter phone system intervention on informed consent. More patients in the post-intervention group significantly met the criteria for adequately informed consent when compared to the pre-implementation group (54% vs. 29%, respectively). Post-intervention LEP patients had statistically higher odds of informed consent in adjusted models when compared to LEP patients in the pre-implementation group (aOR = 2.56, 95% CI 1.15–5.72). The post-implementation group had statistically significant higher odds of understanding the reason for their surgery or procedure (aOR = 3.60, 95% CI 1.52–8.56). The post-intervention group also had statistically higher odds of having all their questions answered (aOR = 14.1, 95% CI 1.43–139.0). When compared to English-speaking patients, post-intervention LEP patients had 62% lower odds of adequately informed consent compared to English-speaking patients (aOR = 0.38; 95% CI 0.16–0.91).
[65]hospital LOS and 30- day readmission ratesretrospective cohort2004–20073071NAtertiary care, university hospitalPatients’ preferred languageSpanish, Portuguese,
Vietnamese, Albanian, Russian, and Other
Patients who did not have an interpreter present on both admission and discharge days were in the hospital about 1.5
days longer than patients who had interpreters on both days. Patients who received interpreters on both admission and discharge days had a mean LOS of 2.57, compared to patients who received interpretation neither on admission nor discharge days had a mean adjusted LOS of 5.06 days. 103/423 (24.3%) patient admissions who did not have an interpreter present either at admission and discharge were readmitted within 30 days, compared to 163/963 (16.9%) of patients with an interpreter at admission only, 85/482 (17.6%) of those with an interpreter at discharge only, and 178/1192 (14.9%) with an interpreter at both admission and discharge day.
[72]Post-discharge reported issuesretrospective cohort2018–201912,2941566academic medical centerEHR listed a preferred
language for healthcare other than English if the patient self-identified as needing an interpreter
Spanish, Cantonese, Russian, Mandarin, Vietnamese, otherMore LEP patients needed assistance getting prescriptions filled (adjusted, 8.3% vs. 5.5%) and had concerns about
their medications (adjusted 12.9% vs. 10.6%). While LEP patients had more post-discharge issues, there was no significant difference in issue severity.
[63]Total joint arthroplasty (TJA)retrospective cohort2015–20194721378urban medical centerlanguage preference
other than English & request for interpreter services
Spanish, Chinese, other non- English languageIn univariate analyses, patients with LEP who underwent TJA had longer LOS (median [IQR], 3 [2,3,4] days vs. 2 [1,2,3]
days), higher costs of hospitalization (median [IQR] $15,000 [$13,000-$22,000] vs. $14,000 [$12,000-$19,000]), and were more likely to be discharged to a skilled care facility (161 patients [42.6%] vs. 889 patients [20.5%]) compared with patients with EP. There was no difference in 30-day readmission rates by language status.
[59]unplanned ED revisit within 72 hours of dischargeretrospective cohort study201232,8572943Mount Sinai
Hospital, a tertiary medical center in NYC
used EHR patient language preferenceNAThe unadjusted odds ratio between LEP status and hospital admission was 1.20 (95% CI 1.11–1.30), but the
association disappeared when controlling for confounding variables. LEP patients had an OR of 1.19 (95% CI 1.02, 1.48) in unadjusted association with unplanned ED revisits within 72 hours. This association became stronger in adjusted variables with an OR of 1.24 (95% CI 1.02, 1.53).
[49]emergency department visits and hospital admissionsretrospective cohort201237841892large primary
health care network in Minnesota
Language spoken by patients and interpreter status in HERSomali, Spanish, Vietnamese, Khmer, Arabic, and OtherThere were significantly more total ED visits (841 vs. 620) and hospitalizations (408 vs. 343) for IS (interpreter service)
patients compared with non-IS patients. The proportion of patients with at least 1 ED visit (23.7% vs. 15.4%) and at least 1 hospitalization (15.1% vs. 10.6%) was significantly higher among IS patients. Nearly twice as many IS patients had 3+ ED visits and hospitalizations than non-IS patients.
[60]admission for emergency surgery from the ED.retrospective cohort201985,8999874quaternary care, urban, academic medical centerpatients used hospital interpreter servicesNALEP individuals had significantly higher odds of admission for surgery compared to EP individuals (OR 1.33, CI 1.17, 1.50), but this difference disappeared after adjusting the models. LEP Hispanics were more likely to be admitted for surgery than non-LEP Hispanics (OR 1.63, CI 1.08, 2.47).
[55]informed consent documentationretrospective cohort (matched chart review)2004–200614874Public teaching hospital in San Franciscoprimary language from HERSpanish, Cantonese, and MandarinEP patients were more likely to have full documentation of informed consent (53%) than LEP patients, who also had
evidence of interpretation (28%). Only 41% of LEP patients had a consent form in their language or had one signed by an interpreter. In the multivariate, adjusted analysis, there were no differences in documentation between the EP and LEP groups, nor between the Spanish and Chinese-speaking patients.
[56]risk of emergency department visit admissionretrospective cohort20179,641,6891,421,385California hospitalsSelected a non-English language as the principal language to communicate with the healthcare providerSpanish, Mandarin, Cantonese, Tagalog, Vietnamese, and OtherLEP patients were less likely to be admitted for diabetes with short-term complications than EP patients (54.0% vs. 70.9%). More LEP patients were admitted to the hospitals than EP patients (median different of 1.3%, IQR = −1.1–5.1%).LEP patients were more likely to be admitted for COPD or asthma in older adults across all models (36.8%, 95% CI 35.0–38.6%] vs. 33.3% in EP patients (95% CI 31.7–34.9%). Admission rates for those who spoke Mandarin/Cantonese, Vietnamese, and or other had a significant difference in admission rate compared to English.
[57]differences in
discharge opioid prescribing for trauma patients
cross-sectional study20181419237Zuckerberg San
Francisco General Hospital and Trauma
English was not among patient self-reported languages spoken.NA41% of LEP patients were discharged on opioid medications. In multivariable models, EP patients had 1.63 adjusted
increased odds of receiving any opioid prescription at discharge. EP patients received 147 oral morphine equivalents (OMEs) on average, compared with 94 OMEs for LEP patients.
[58]birth outcomes (Cesarean sections, VBACs)cross-sectional201211,4191149HI hospitals that
collected language preference
Preferred language noted at intakeMicronesian,
Japanese, Tagalong, Spanish, Ilocan, Visayan, Mandarin, Cantonese, Chuukese, Marshallese, Tongan, Somoan, Hawaiian
There was a significant difference between primary Caesarean deliveries between EP and LEP (RR = 1.18), with a higher relative risk for patients with diabetes (RR = 1.30). There is also a significant difference in vaginal birth after Cesarean (VBAC) between EP and LEP (RR = 1.02).
[67]LOSprospective cohort2011245124Level 1 trauma
academic emergency department
Preferred primary language recorded during registrationSpanish, Navajo, Vietnamese, Chinese, ArabicThere were no differences in mean LOS from arrival time to the time seen by a provider when comparing EP patients
to LEP patients. There were also no mean LOS differences from arrival time to discharge or admission decision when comparing LEP to EP patients.
[70]diagnostic test orders with chest & abdominal painprospective cohort1997–1998324172Public hospital emergency departmentEnglish speaking proficiencySpanish, Cantonese,
Hindi, Mien, Arabic, Russian, Mandarin, Korean, and other
No diagnostic test was found to be statistically significantly different between EP & LEP patients with chest pain. The
frequency of ordering of CBC counts, serum electrolyte determinations, urinalyses, ECGs, and abdominal CT scans was found to be statistically different between English-speaking and non–English-speaking patients with abdominal pain.
[61]emergency medical services scene and transport timesretrospective case- control study2012201100Albuquerque
Ambulance Service and emergency
Inability to sign the EMS run report secondary to language barrierNALEP patients had greater odds of calling 911 for trauma (OR, 2.5; CI, 1.4–1.5). LEP patients had longer transport times
(mean difference of 2.2 minutes, CI, 0.04–4.0). LEP patients were more likely to have an electrocardiogram (ECG) done in EMS (OR, 3.7; CI 1.7–8.1) and ED care (OR = 2.0: CI, 1.1–1.3). LEP patients were more likely to leave without being seen or leave against medical advice (OR = 0.2; CI 0.1–0.7).
NA means not available in the published manuscript. Abbreviations used in the table include the following: LEP, limited English proficiency; EP, English proficient EHR, electronic health record; LOS, length of stay; ED, Emergency Department; EMS, Emergency Medical Services.

3.3. Screening Studies

There were 25 studies looking at screening outcomes that met our inclusion criteria [40,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102]. The most common screening type among these studies was cancer screening, including cervical, breast, and colorectal cancers. Other screening topics included HIV testing, Hepatitis B testing, and cholesterol screening. The majority of these studies were cross-sectional, with three retrospective cohort studies [40,79,95], and one randomized controlled trial [88]. Datasets that were used to conduct some of these studies include the California Health Interview Survey (CHIS), the Behavioral Risk Factor Surveillance System (BRFSS), the Texas Behavioral Risk Factor Surveillance Survey, and the Medical Expenditures Panel Survey (MEPS). One study used data from the Study of Women’s Health Across the Nation (SWAN) to conduct their research [87]. Two studies looked at the use of interpreter services and their relationship with breast and cervical cancer screening use [83,102]. The data used for screening studies are generally older, with the earliest being from 1995. Most studies in this group used data from before 2015, with the most recent data being from 2018. Within the studies that specified language groups, nine studies looked at Spanish speakers, six studies looked at Chinese languages (Mandarin and Cantonese), nine studies looked at other Asian languages (including Korean, Vietnamese, Cambodian, Laotian, Japanese, Thai, Tongan, and Khmer), and three studies looked at Russian, Arabic, Somali, and Amharic. As in the other healthcare categories, individuals who spoke Spanish and Asian languages were the populations most often included in the studies. A majority of these studies were ranked as low or moderate in terms of quality. This was mainly due to their cross-sectional study design, which limits the ability to determine causality, small LEP sample sizes, differences in LEP definitions, and limited language groups included, which can limit the generalizability of these studies.
Overall, the screening studies showed that LEP individuals were less likely to receive cervical, breast, and colorectal cancer screening compared to EP individuals. However, there was some variability in these findings. The impact of LEP on breast cancer screening was the most variable. There were four studies that showed no significant difference between LEP and EP populations in mammogram screenings [40,80,97,101]. However, five studies showed that LEP individuals had lower odds of receiving a mammogram compared to EP individuals [83,85,87,90,100]. In a study by Sheppard et al., endorsement of breast cancer screening was more likely among women whose primary language was English compared to those who spoke a non-English language [99]. LEP individuals were shown to be less likely to have heard of [81] and received a clinical breast exam [81,83,85,87] or to have given themselves a breast self-exam [86].
Cervical cancer screening studies looked at pap smears and largely found that LEP populations had lower rates of pap smear exams compared to EP populations. Eight studies found that LEP individuals were significantly less likely to have had a pap smear regularly or ever compared to EP individuals [81,83,85,87,88,90,91,101]. There were four studies that found no statistically significant impact of LEP on cervical cancer screening among Chinese- [97] and Spanish-speaking populations [40,80,102].
Of the studies that examined colorectal cancer screening (CRC), five found that LEP respondents were less likely to utilize these screening services [89,92,95,97,101]. One study found that LEP Latino men were the least likely to report CRC test use compared to non-LEP Latino men, non-LEP and LEP Latino women, and all non-Latino subgroups [84]. Another study found that, compared to non-LEP Mexican-Americans, those with LEP were less likely to have had CRC testing [89]. A majority of the studies that analyzed CRC screening looked at tools such as the fecal occult blood test, endoscopy, or colonoscopy. One study looked at CRC screening using a multi-target DNA (mt-sDNA) stool test and found that LEP patients were less likely to successfully complete the mt-sDNA test compared to EP patients. In this study, the return times for completed tests among LEP patients were twice as long as the return times of EP patients [79]. There were two studies that showed no impact or a mixed impact of LEP on CRC screening. Breen, Rao, and Meissner found no significant difference between LEP and EP Mexican-Americans in CRC screening [80]. A study by Jacobs et al. found that there were significantly lower rates of fecal occult blood testing among the LEP population. However, after the implementation of interpreter services, the significant differences in screenings between the LEP and EP populations disappeared [40].
Some studies looked at additional factors that could influence the impact of LEP on screening, such as the combination of LEP and language concordance with providers, border residence status, and low health literacy. In a study that analyzed low health literacy (LHL) and LEP both separately and together, LEP alone was not significantly associated with meeting screening guidelines (breast, cervical, and CRC). However, respondents with both LHL and LEP were less likely to meet breast cancer and colorectal cancer screening guidelines [98]. Another study reported that LEP-only respondents were less likely to meet CRC screening guidelines than LHL-only respondents [97]. Both articles examined patient-provider language concordance among the LEP population, but only one found that not having a language-concordant provider was significantly associated with lower utilization of a mammogram [98]. Another study that analyzed patient–provider language concordance found that those in the language-discordant cohort (did not speak English at home and no one at their providers spoke their language) were just as likely as the English-concordant cohort (spoke English at home) to be adherent to CRC screening guidelines [95]. The last of the four studies found that Spanish-speaking Texan Mexican-Americans who were border residents had low rates of breast and cervical screening use compared to those who were Spanish-speaking and non-border residents. However, after controlling for enabling factors (health insurance, income, and a usual source of care), the significance of the language of the interview and border residence disappeared among participants [85]. Studies like these demonstrate that it can be difficult to isolate the effects of LEP from interrelated socio-economic, geographic, and language service provision in the healthcare setting.
There were three studies that looked at non-cancer-related screenings. One study looking at Hepatitis B (HBV) found that LEP men who spoke Vietnamese were more likely to report past HBV testing compared to the LEP population [82]. Another study looked at HIV and found that Spanish-speaking LEP men who have sex with men were less likely to receive HIV testing compared to their EP counterparts [96]. Kenik, Jean-Jacques, and Feinglass looked at cholesterol screening and found that LEP Spanish speakers were more likely to never have been screened for high cholesterol compared to the EP population [93]. Differences in the studies may be due to differences in linguistic and cultural groups (two studies among Spanish-speaking populations and one among Vietnamese populations), as well as the type of screening. Please see a list of studies included in this category with key summary information in Table 5 below.
Table 5. Screening Study Details.
Table 5. Screening Study Details.
Screening Studies
Health OutcomeStudy DesignStudy
Size (n=)
SettingLEP definitionLanguagesStudy Outcomes (LEP Related)
[80]cervical, breast, and two types of colorectal cancer test usecross-sectional20019079Men = 1786;
Women = 2425
CaliforniaRespondent took the interview in SpanishSpanishThere was no significant difference between LEP and EP among Mexican-American women who had a mammogram and pap test. There was no significant difference between LEP and EP among Mexican-American men and women who had a colorectal cancer screening test.
[81]knowledge and utilization of breast and cervical cancer early detection practicescross-sectionalNA135; cervical cancer survey sample = 3563; cervical cancer survey sample = 21community sites in New York CityParticipants assessed their English speaking ability as not at all, poor, or averageChineseEP women were more likely to have heard of the clinical breast exam (38%), compared with the women who judged their language abilities as either totally lacking (15%) or else poor (13%) and were more likely to have had a clinical breast exam in the previous year compared to LEP participants. EP participants were more likely to believe that they needed a pap smear compared to LEP participants (p < 0.01), and were more likely to have had a pap smear (50% EP v 28.6% poor English and 28.6% not at all) within a year of the survey.
[82]serologic HBV testingcross-sectional2002509262Seattle, WashingtonEnglish proficiency determined by “speaks fluently or well”, “speaks quite well”, and “does not speak well or at all”VietnameseLEP was independently associated with higher odds of past HBV testing (OR = 2.5; CI = 1.3–4.7) compared to high English proficiency.
[83]receipt of mammogram, clinical breast exam, and pap smearcross-sectional2002–200317081284CaliforniaPreferred language to speak to doctor or medical providerCambodian, Laotian, Thai, and TonganLEP immigrants had significantly lower odds of receiving a mammogram (OR = 0.46), clinical breast exam (OR = 0.59), and pap smear (OR = 0.40) compared to EP immigrants.
[84]colorectal cancer screening uptakecross-sectional200899,8832362United StatesSurvey was completed in SpanishSpanish48.2% of LEP Latino men had the lowest adjusted screening rates compared to all the other Latino subgroups, which include Latina women with LEP (56.2%). Compared to non-Latino White men, LEP Latino men were the least likely to report colorectal cancer (CRC) test use (AOR 0.47; CI 0.35–0.63).
[85]cancer screeningcross-sectional2000- 200423991020TexasLanguage of interviewSpanishWomen that did the interview in Spanish and are border residents are less likely to utilize screening services. Those interviewed in Spanish are associated with a lower likelihood of having a pap smear (OR = 0.732, CI = 0.537, 0.998), clinical breast exam (OR = 0.489, CI = 0.383, 0.624), mammogram within the past two years (OR = 0.660 CI = 0.442, 0.986) after controlling for age and educational differences.
[79]colorectal cancer screening completion ratesretrospective cohort study2015–2018412103Primary care clinic in the Midwestidentified in the EHR need for an interpreterSomali, Cambodian, Vietnamese, Arabic, and other.The percentage of mt-sDNA tests without useful results was 53.4% (55/103) among patients with LEP compared to 29.1% (90/309) among EP patients (p < 0.0001). This study demonstrates a significant disparity in colorectal cancer screening completion using the mt-sDNA test among populations with LEP.
[86]cancer screening health behaviorscross-sectionalNA99NACommunity
center for refugees and immigrants
Asked to rate their English speaking ability.RussianEnglish language was the only acculturation measure that was significantly related to behaviors and outcomes. Women who spoke and understood English better were more likely to conduct a breast self-exam (p < 0.05).
[87]receipt of Papanicolaou tests, clinical breast examinations, and mammographycross-sectional1996- 19971247No English = 278;
Another language more fluently than English = 66
Oakland, CA; Los Angeles, CA; and Newark, NJAsked what language they usually read and spokeSpanish, Cantonese, or JapaneseNot speaking or reading English (Pap: OR = 0.43, CI = 0.34, 0.54; CBE: OR = 0.44, CI = 0.35, 0.57) or speaking another language more fluently than English (Pap: OR = 0.50, CI = 0.35, 0.72; CBE: OR = 0.55, CI = 0.38, 0.80) significantly reduced the likelihood of receipt of Pap testing or CBE (p < 0.01). Those who reported not speaking or reading English were less likely to receive a mammogram (OR = 0.63, CI = 0.50, 0.80).
[40]receipt of preventative health screeningsretrospective cohort study1995–19974380327Four HMOs in New EnglandUse of interpreter servicesSpanish & PortugueseFor receipt of screening services the study found significantly lower rates of FOB testing and rectal exams, but no significant difference in mammograms, breast exams, and pap smears, in the LEP compared to the EP population. After implementation of interpretation services the significant differences in screenings between LEP and EP populations disappeared.
[88]regular cervical cancer screeningrandomized controlled trial2003- 2004473NAWashington, DC metropolitan areaasking participants their ability to read, write, listen to, and speak English, ranging from “not at all” to “very good.”Mandarin,
Cantonese, Taiwanese, and Fuzhou
Women with higher English proficiency were more likely to have received regular Pap tests than women with LEP (OR, 1.39; CI, 1.13–1.72).
[89]colorectal cancer test ratescross-sectional200518,304590CaliforniaSpeaks “no English”, or “does not speak it well” at homeSpanishThose with LEP were 1.68 times more likely to have never had any CRC test (p < 0.01) (blood test or endoscopy). Among Mexican Americans, non-LEP respondents were significantly more likely to have had fecal occult blood test (FOBT) only (10% vs. 16%; p = 0.01), both tests (11% vs. 29%; p < 0.01), and to have ever had any test (45% vs. 67%; p < 0.01), compared to LEP respondents.
[90]breast and cervical cancer screening behaviorscross-sectional1998- 1999438NAMarylandEnglish language
proficiency was assessed by asking respondents to rate their English
KoreanKorean women who speak some English (OR = 1.98; CI, 1.07, 3.67) and those who speak English very well (OR = 2.41; CI, 1.03, 5.62) reported greater odds of having a mammogram compared to those that speak little English.
[91]regular cervical cancer screeningcross-sectional2000459NAMarylandSpoken English
proficiency ranked as none/little; average, good/fluently
KoreanIn the bivariate analysis, spoken English proficiency was identified to be significantly related to having regular pap smears (p < 0.05).
[92]cancer screeningcross-sectional2000–200155,428NACaliforniaDoes not speak English at homeSpanish, Mandarin,
Cantonese, Vietnamese, Korean, or Khmer
Individuals who do not speak English at home were less likely to get screened for colorectal cancer (OR 0.75; CI, 0.58–0.98).
[93]cholesterol screeningcross-sectional2011389,03924,509United StatesQuestionnaire completed in SpanishSpanishThere was a significant difference between LEP (68.8%) and EP (88.7%) population in cholesterol screening within the past 5 years (p < 0.000). LEP Spanish speaking individuals were more likely to never have been screened for cholesterol (OR = 1.43; CI, 1.22–1.69) compared to EP individuals even after controlling for socio-demographic factors.
[94]cervical cancer screening behaviorscross-sectional20159743a Midwestern citySpoke English not at all or not too wellNA23.1% of LEP individuals who spoke English not at all had ever received a pap smear. 56.7% of LEP individuals who spoke English not too well had ever received a pap smear.
[95]colorectal cancer screening ratesretrospective cohort study2002–200623,2971703NANot comfortable conversing in EnglishSpanishNon-English speakers had a lower use of colorectal cancer screening (30.7% vs. 50.8%; OR, 0.63; CI, 0.51–0.76). The adjusted odds of being current with CRC screening was lower for those in the Other Language-Concordant cohort compared to those in the English-Concordant cohort (OR, 0.57; CI, 0.46–0.71). The Other Language-Discordant cohort did not statistically differ from the English-Concordant cohort (OR, 0.84; CI, 0.58–1.21).
[96]HIV testingcross-sectional2012–2015304194North CarolinaSpeaking comfortably in only SpanishSpanishLEP men who have sex with other men were 0.31 times less likely to receive HIV testing compared to EP (CI, 0.16–0.57).
[97]meeting colorectal cancer screening guidelinescross-sectional200715,888539CaliforniaLEP is defined as self-
reporting speaking English “not well” and “not at all.”
Mandarin, Cantonese, Korean, and VietnameseIndividuals with LEP only (OR = 0.60) and LEP plus limited health literacy (OR = 0.52) were significantly less likely to meet colorectal cancer screening guidelines. Among the 539 individuals in the sample with LEP, 54.5% had a language- concordant provider.
[98]meeting guidelines for cervical, colorectal and breast cancer screeningcross-sectional2007cervical= 632; colorectal = 488; breast = 326.cervical = 201; colorectal = 181; breast = 153Californiaself-reporting speaking English “not well” and “not at all”Cantonese and MandarinLEP was not independently significantly associated with meeting any of the screening guidelines for breast, cervical, or colorectal cancer comparing LEP to EP among the Chinese population.
[99]endorsement of breast cancer screeningcross-sectionalNA20091Washington, DCPrimary language labeled as “other”Amharic and otherEndorsement of breast cancer screening was more likely among women whose primary language was English compared to those who spoke a non-English language (OR = 3.83; CI: 1.24 to 11.87).
[100]colorectal, breast, and cervical cancer screeningcross-sectional2012- 2013NANANorthern
California outpatient healthcare system
Primary language is not EnglishNALEP individuals are 0.81 times less likely to receive a mammography screening (CI: 0.71, 0.92). LEP individuals are 0.79 times less likely to receive a colorectal cancer screening (CI: 0.72, 0.87).
[101]accessing coloscopy,
mammography, and papanicolaou smear screening.
cross-sectional2013- 20151298NANew York CityNANAEnglish language proficiency was a significant barrier for some screening methods such as colorectal cancer screening with colonoscopy, and cervical cancer with pap smear, but not for mammography. Non-English speakers are significantly less likely to have a pap smear (OR = 0.24, CI= 0.14–0.41) compared to English speaking participants.
[102]papanicolaou smear screening accesscross-sectional2007–2008318271Boston, MANeed a translator during a healthcare encounter.SpanishThere was no significant difference in likelihood of having less than 5 or 5 or more lifetime pap smears between women who report that they need a translator during a healthcare encounter.
NA means not available in the published manuscript. Abbreviations used in the table include the following: LEP, limited English proficiency; EP, English proficient; HER, electronic health record.

3.4. Specific Condition Studies

We found 40 studies investigating specific conditions that met our inclusion criteria [12,13,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138]. Overall, these studies showed many similar patterns to the other studies in our analysis, such as small LEP sample sizes and wide variability in how the LEP population was defined. Spanish was overwhelmingly the most studied language in this group, with 33 studies explicitly including Spanish speakers. Other languages studied seemed to vary regionally, with Chinese languages being the second most studied. As was the case throughout our review, nearly all of the studies in this category were observational, and half of them (20 in total) were retrospective chart reviews. This choice of study design makes practical sense, as intervention studies of specific conditions (such as cancer drug trials, for example) are ethically complex and require significant institutional resources. Our analysis found two papers using data from one randomized controlled trial [123,139]. This trial was seeking to compare two different methods of language interpretation. There were no other interventional studies in this category. The types of conditions studied skewed toward chronic conditions, including diabetes and related conditions (13 studies), treatment of various cancers (four studies), mental health conditions (five studies), hypertension (three studies), and asthma (two studies). Two studies looked at Hepatitis B serologic status. One study investigated TBI, one investigated heart failure, one looked at blood clot prevention, and one looked at acute stroke care. The remaining seven studies investigated outcomes for different types of surgical procedures, including cataract surgery and post-tonsillectomy hemorrhage. Studies primarily looking at more acute cancer-related surgery outcomes (two studies) are grouped with other surgical studies due to similarities in the types of health outcomes being investigated.
Because of the wide variety of clinical targets for specific conditions, it is more difficult to draw general conclusions about outcomes in this category of study. However, the vast majority of studies in this category investigated conditions, whether acute or chronic, that have at least one agreed-upon, objectively measurable, condition-specific benchmark. In conditions such as diabetes, for example, the laboratory measurement of HgbA1c is a benchmark; in hypertension, the benchmark is a vital sign; in acute stroke care, the benchmarks include door-to-imaging time and administration of tPA; in neurologic conditions such as dementia and TBI, the benchmarks are the results of standardized clinician-administered cognitive testing, etcetera. In studies looking at objectively measurable clinical outcomes such as these, outcomes were almost universally worse for LEP populations. There were a few interesting exceptions, however. Four studies appeared to find no significant differences among study populations; three of these were looking at diabetes and one at acute stroke. However, one of those studies looked only at LEP patients in order to compare different types of language interpretation and found poor glycemic control across the entire sample [139]. A second study in this group, also looking at diabetes, found poor glycemic control across all Hispanic patients, regardless of preferred language [122]. The third study of diabetes that appeared to find no significant difference in outcomes for LEP populations was actually looking at a group of clinics that had a high proportion of bilingual staff, and although the data analysis was otherwise rigorous, this study did not account for the potential interfering factor of language concordance between staff and LEP patients [124]. Of the four exceptions, the study of acute stroke is the most interesting, finding no significant difference in outcomes for LEP patients in any of the acute stroke care benchmarks, but it is limited in that it looked exclusively at a single stroke center and had a relatively small sample size [104].
In some studies, particularly those looking at hospital-based treatments such as surgeries or acute treatment of heart failure [132], target health outcomes were more uniformly defined and similar to the findings outlined in the other hospital care studies we found. Such studies tended to look at outcomes such as the rate of any complication, procedure-related mortality, hospital length of stay, 30-day readmission rate, and discharge disposition. This group of studies had the highest proportion of neutral outcomes; that is, five of the seven studies in this group found no significant difference in outcomes for LEP populations. It should be noted, however, that all of the studies in this group had relatively small LEP patient sample sizes, and most were looking at only a single hospital or care center.
A third group of studies looked at outcomes that suggested whether or not recommended care had taken place. Included in this group are two studies of surgeries that looked at whether or not a recommended procedure took place and a study of Serious Mental Illness (SMI) that looked at contact points for mental health care [116]. The surgery studies were looking at cataract surgery [106] and at various types of surgery for breast cancer [125]. The outcomes of these studies are more challenging to interpret. In the cataract study, when those with visually significant cataracts were compared with those who had obtained cataract surgery, those who spoke English were nearly twice as likely to have obtained surgery [106]. However, this study was a cross-sectional population survey, meaning that cause and effect cannot be inferred. In the breast cancer surgery study, rates of recommended procedures were examined across many types of cancer, and while it seems encouraging that no significant difference was found between groups, the study was limited to a single center, and the LEP population size was less than 60 people [125]. The most interesting results were from the SMI study, which was more of an attempt to gather information about how LEP patients with SMI first contacted mental health services in a single urban area. This study found that LEP patients tend to prefer outpatient contact over emergency department contact. However, this study included data from a large outpatient clinic that was specially designed to serve exclusively East Asian LEP mental health patients, with a large number of multilingual staff, and the study authors themselves note that this could have biased the results [116].
Another group of studies looked at patient adherence to best practices for self-management of specific conditions, including three looking at diabetes self-management [111,119,128], one looking at treatment adherence for cardiovascular disease [136], and one looking at adherence to warfarin in the treatment of blood clots [133]. One study showed that LEP Latinos were less likely to adhere to oral medications and insulin compared to EP diabetic patients [111]. A second study showed that LEP Latinos were more likely to have a less-than-daily practice of self-monitoring blood glucose among Type 2 diabetic patients treated pharmacologically, although there was no significant difference shown among Type I diabetics [119]. These mixed results for diabetes management adherence may be due to differences among language groups and differences in measures of self-management. In the study by Njeru et al., while LEP patients had a lower percent likelihood of meeting recommendations for A1c and LDL levels when adjusted for sociodemographic risk factors, there was found to be no significant association between LEP and diabetes management. The one exception was blood pressure, where LEP individuals were more likely to meet the guidelines than non-LEP patients [128]. Both the warfarin and cardiovascular disease studies showed a lower likelihood of LEP populations being in the therapeutic range (for warfarin dosing) and having good adherence to cardiovascular disease treatment medications, including lipid, blood pressure, and glucose medications.
The remaining studies in this category targeted depressive disorders. Because of the nature of this condition, all three of these studies tracked outcomes using a subjective symptom scale that relied on patient self-report. Interestingly, each of the three depression studies used a different symptom scale, making cross-study comparisons impossible. However, the fact that so few studies of this type of mental health condition appeared in our review is notable and suggests the additional complexity involved in collecting subjective or qualitative health data in LEP populations. Two of these studies appeared to find a link between better English proficiency and an increased likelihood of either obtaining a depression diagnosis [123] or testing positive on a depression screening test [127]. Interestingly, both of these studies were focused on Asian patients. In the third study, which focused on Mexican-American patients exclusively, the depression symptom scores of the LEP group were found to increase at a faster rate over time [121]. Overall, these studies again bear out the overall pattern of poorer health outcomes in LEP populations. Please see a list of studies included in this category with key summary information in Table 6 below.
Table 6. Specific Condition Study Details.
Table 6. Specific Condition Study Details.
Condition Citations
Health OutcomeStudy DesignStudy PeriodTotal Sample Size
(N =)
LEP Sample Size
(n = )
SettingLEP DefinitionLanguagesStudy Outcomes (LEP Related)
[103]clinical diagnosis of diabetic peripheral neuropathy recorded in the EHRcross-sectional2003–200812,6811626Kaiser
Permanente of Northern California
asked if respondents had difficulty understanding English NALEP was independently associated with absence of clinical documentation of diabetic peripheral neuropathy in the EHR, despite reporting symptoms when surveyed. [RR 0.80 (0.68, 0.94)]
[104]acute stroke care benchmarks and mortality rateretrospective cohort2013–2016928282UC Irving Stroke Center (inpatient)preferred language as indicated on admissionSpanish, OtherThere was no statistically significant difference in acute stroke care benchmarks between LEP patients and patients whose preferred language was English
[105]access to specialist care for colorectal cancercross-sectional1999–2000107975Participants from
9 northern California counties
self-report of language spoken at homeSpanishWhite LEP people reported significantly more problems with access to care than other groups, including Hispanic and Asian LEP people (p< 0.001).
[106]cataract surgerycross-sectional1997–19994774NAoutpatient clinics
in Arizona, specifically Pima and Santa Cruz
Preferred language on interview was “mostly Spanish” rather than “Spanish and English”Spanish and EnglishComparing those who obtained cataract surgery with those having visually significant cataract (i.e., those needing surgery), speaking English (OR, 1.80; p = 0.04) was significantly associated with having obtained cataract surgery, even after adjusting for demographic variables and other potential risk factors.
[107]participation in diabetes self-care measurescross-sectional2009–2010250250outpatient clinics in rural Californianot stated—study included only Spanish- speaking participantsSpanishSpanish-speaking type 2 diabetes patients who had a Spanish-speaking provider reported engaging in diabetic foot care more frequently than those who did not have a Spanish-speaking provider (1.4 days vs. 0.7 days per week, p= 0.01).
[108]Clinical variables
related to diagnosis and treatment of squamous cell carcinoma
retrospective cohort2014–201947751single cancer treatment center in Bostonpreferred language at time of patient registrationSpanish, Mandarin,
Vietnamese, Farsi, Greek and Haitian Creole
The LEP patients were diagnosed with cancer at a later overall stage (p = 0.03) and less frequently treated with surgery alone compared to English speaking patients (p < 0.001). After adjusting for stage and site, LEP patients were significantly more likely to receive primary surgical management compared to primary non-surgical management [OR
=2.29 95% CI (0.93, 5.58), p = 0.008].
[109]high BP measurement in the absence of a self-reported diagnosis of hypertension, and/or a hypertension med prescriptioncross-sectional1993–19942597NACommunity
setting, 5 southwestern states
Used three separate but
overlapping LEP definitions, and reported on each separately:
SpanishThose who used Spanish more than English for mass media were twice as likely to have undiagnosed hypertension than those who used primarily English.
[110]Cancer-related surgery
outcomes, including LOS, 30-day ED
revisit, all-cause
retrospective cohort2012–20172467824Inpatient; single urban hospitalLEP status was
determined by examining language concordance between
NAAfter adjusting the results for insurance status, comorbidities, and other factors, there was no difference in surgery outcomes found between the LEP and EP groups
[111]adherence to
prescribed hypoglycemic medication
retrospective cohort2006–201230,8383205Kaiser
Permanente Northern California
preferred language was Spanish in electronic health recordSpanishLEP Latinos were more likely to be non-adherent to oral medications and insulin than English-speaking Latinos [RRs 1.11–1.17, p < 0.05] or Whites [RRs 1.36–1.49, p < 0.05].
Permanente Northern California
self-report; DISTANCE
survey asked if respondents had difficulty understanding
SpanishAmong LEP Latinos, having a language discordant physician was associated with significantly poorer glycemic control (OR 1.98; CI 1.03–3.80).
[112]LDL and systolic BPretrospective cohort2005–20067359542Kaiser
Permanente Northern California
self-report; DISTANCE
survey asked if respondents had difficulty understanding
SpanishThere were no statistically significant differences between LEP and non-LEP patients in terms of BP control. Among Latinos, LEP patients were less likely to have poor lipid control than English-speaking patients (odds ratio, 0.71; 95% CI, 0.54–0.93), with no difference by LEP patient–physician language concordance. LDL control was poor across the entire study group.
[114]Undiagnosed dementiacross-sectional20117385362Used data from a
nationally representative study
Responding “not well”
or “not at all” when asked how well patients understand or speak
NAOlder adults with LEP were found to have 3.10 higher odds of possible dementia (95% CI 2.06–4.66). LEP was associated with significantly greater odds of undiagnosed dementia (OR = 2.95, 95% CI 1.70–5.12). LEP accounted for 87.6% of the foreign-born status effect on possible dementia, ad it explained 56.1% of the foreign-born status effect on undiagnosed dementia.
[115]adherent to antipsychotic medications, hospitalization and health care
retrospective cohort1999–200431,5602823San Diego Countyself-reported preferred languageSpanish and Asian languagesA greater proportion of LEP Latinos were adherent compared to English proficient Latinos (41% vs. 36%, respectively, p = 0.002). A lower proportion of LEP Asians were adherent compared to their English proficient counterparts (40% vs. 45%, respectively, p = 0.034). LEP Latinos were less likely than English proficient Latinos to experience psychiatric admissions (17% vs. 21%, p < 0.001); non-psychiatric admissions (20% vs. 22%, respectively, p = 0.014); and overall inpatient admissions (33% vs. 38%, respectively, p < 0.001). LEP Latinos and Asians had the lowest overall costs- healthcare services and pharmaceuticals per year (15,883 USD and 15,138 USD, respectively) compared to other groups (adjusted for adherence).
[116]first point of contact
with public mental health services, service utilization for 18
retrospective cohort2000–200592431108public mental
health services in San Diego county; included
Preferred language as listed in EMRSpanish, Vietnamese, TagalogLEP patients are significantly less likely to first contact mental health services through an emergency department, and more likely to use an outpatient clinic. They are also significantly less likely to use emergency services within the first 6 months of treatment, and more likely to seek outpatient services (p < 0.001 for each comparison).
[117]HgbA1c, BP, LDLcross-sectional2003–20185017889national survey
administered in a community setting
Anyone who completed
the survey in a language other than English or used an interpreter
Spanish, Other Compared to English-speaking participants, the LEP group that spoke a language other than Spanish (199 participants) were more likely to have elevated HbA1c (OR = 1.6, 95% CI = 1.1, 2.4) or a combination of elevated HbA1c, elevated LDL, and elevated BP (OR = 3.1; 95% CI = 1.2, 8.2).
[118]30-day post-op complications and readmissions after non- emergent infrainguinal bypass surgeryretrospective cohort2007–201426151Inpatient, single urban hospitalPreferred language in medical recordSpanish, Portuguese
Creole, Haitian Creole, Albanian, Other
No statistically significant difference in outcomes was found between the LEP group and the EP group.
[119]self-monitoring of blood glucosecross-sectional1994–199744,181168Kaiser Permanente Northern Californiarequested a materials in
a non-English language, used a Spanish-speaking interviewer for survey, interviewer assessment
NAThe LEP population was more likely to have a less-than-daily practice of self-monitoring blood glucose (SMBG) among type 2 diabetic patients treated pharmacologically (OR 1.3, CI [1.2–1.5]), although there was no significant difference shown among Type I diabetics in SMBG practice. In a sub-group analysis there was a significant difference between Type I diabetic Hispanic LEP and EP populations in checking SMBG greater than 1 time daily, but not in greater than 3 times daily.
[120]Hypertension as
defined by systolic BP over 140 or diastolic BP over 90
retrospective cross-sectional2003–201223,3823269used data from a
national survey administered in a community
Anyone who completed
the survey in a language other than English or used an interpreter
Spanish, Other LEP was associated with an odds ratio of 1.47 (95% confidence interval: [1.07–2.03]) for having elevated BP
[121]CES-D scores (depression screening tool)prospective cohort, longitudinal1993–200729451793community
setting in 5 southwestern states
self-report of speaking
English “not at all” or “not too well” on study survey
SpanishThe CES-D scores of LEP patients increased at a more rapid rate over time during the study period.
[122]HgbA1cretrospective cohort1997–199818379outpatient public clinics in Denver, CORecord of spoken
language in the administrative database, then confirmed by
SpanishLEP patients had no significant difference in glycemic control. However, the study only looked at Hispanic patients, and noted glycemic control was equally poor for the entire sample, regardless of language ability.
[123]Depressive disorder
diagnosis and/or prescription of anti- depressant
RCT, nested cohort2003–2005782NAPrimary care clinic at NYC hospitalParticipants were asked
if they preferred an interpreter. If yes, they were considered LEP,
Spanish, ChineseAmong BDI-FS positive patients, Chinese-speakers were less likely to be diagnosed with depression compared with English speakers (31% vs. 10%, p < 0.05).
[124]HgbA1c, self-reported hypoglycemic eventscross-sectional2011–20121053793outpatient
community health centers in Northern
Language preference for
the survey. Preference for a language other than English meant LEP
Spanish, ChineseThe study found no significant difference in measured health outcomes between LEP and non-LEP groups
[125]Rates of specific breast
cancer surgery, receipt of recommended breast cancer treatment
retrospective cohort2008–201841759Outpatient
comprehensive cancer center in an urban area
Requiring an interpreterSpanish, otherNo difference was found between the LEP group and EP group in terms of breast cancer outcomes. The LEP group had a lower all-cause mortality rate in the unadjusted analysis
[140]LOS, discharge
disposition, and 30-day readmission rate
retrospective cohort2015–20192232146UCSF
neurosurgical center
self-report of English
not primary language and preference for interpreter services at
Spanish, ChineseAn association was found between LEP and longer LOS (incidence rate ratio 1.11, 95% CI 1.00–1.24), and discharge to skilled care (OR 1.76, 95% CI 1.13–2.72), which remained after adjusting for confounders. There was no difference in 30-day readmission rates by language status.
[126]Glasgow Outcome
Scale-Extended scores at 6 months post- injury, access to rehab
retrospective cross-sectional1998–200547642urban Level 1 trauma centerBecause of the nature of
the injuries being treated, definition was twofold: If patient was
SpanishLEP was associated with an odds ratio of 15.093 (95% CI [1.632–139.617]) of having a GOSE score indicative of severe disability 6 months post-injury. This was true even though no statistically significant difference was found for LEP patients in terms of either severity of initial injury, or access to rehab services.
[127]Positive PHQ-2
screening test, indicating depression risk
cross-sectional2013–20161532519Community settingSelf-report of speaking English “not well” or “not at all”NAThe study did not find a consistent, statistically significant link between LEP and depression risk. However, among South Asians, increased depression risk was associated with greater English proficiency (OR = 3.9, 95% CI: 1.6–9.2)
[128]diabetes managementretrospective cohort2012–201313,4561486Minnesota Mayo
Clinic and Hennepin County Medical
need interpreter servicesNALEP patients were less likely to meet guideline outcome recommendations for hemoglobin A1C (66.9 vs. 73.9%;
p < 0.000) and LDL-C (59.3 vs. 71.4%; p < 0.0001), but more likely to meet guideline outcome recommendations for blood pressure (83.3 vs. 75.9%; p < 0.000). In adjusted regression analyses LEP patients were more likely to meet guideline outcome recommendations for blood pressure <140/90 (OR, 2.02 CI [1.7, 2.4]) compared to non-LEP
[129]HgbA1c, systolic BP, and LDL cholesterolcohort2007–201316051605outpatient clinics
in the Kaiser Permanente Northern
self-report of Spanish as primary language in EMRSpanish LEP patients who switched to a language concordant provider had significantly better A1c and LDL control vs. those who switched between two language discordant providers. After adjustment, the prevalence of glycemic control increased by 10% (95% CI, 2% to 17%; P = 0.01), and LDL control increased by 9% (95% CI, 1% to 17%; p = 0.03).
[130]Incidence of post-
tonsillectomy hemorrhage, and operative or non-
retrospective cohort2015–202024661026Inpatient head and neck surgery center in Bostonprimary language preference in medical recordNAThere were no statistically significant differences in disposition or outcomes for LEP patients.
[131]Treatment outcomes in
head and neck cancer (HNC) patients receiving curative
retrospective cohort 2004–201013120Private, non-
profit, urban academic medical center
Primary language spokenSpanish, Portuguese,
Russian, Vietnamese, Arabic, Mandarin, Haitian
English proficiency was significantly associated with an improved three-year locoregional control (LRC) among EP patients (82.2%) when compared to LEP patients (58.3%). LEP patients who received chemoradiation had inferior 3 year LRC when compared to the LEP patients who only received radiation (29.2% vs. 87.5%). LEP was determined to be a significant predictor locoregional failure (LRF), though the significance went away after adjusting for race/ethnicity.
[132]30-day readmission rateprospective cohort201214545Columbia
Presbyterian hospital in New York City
Preferred language on admissionSpanishThe hazard ratio for 30-day readmission for patients who did not speak English as a primary language was 2.2 (p = 0.052).
[133]time in therapeutic range with warfarinretrospective cohort2009–20103770241Massachusetts General Hospitalself- reported speaking English less than “very well”NALEP patients compared with non-LEP patients spent less time in therapeutic range (71.6% versus 74.0%, p = 0.01) and more time in danger range (12.9% versus 11.3%, p = 0.02). In adjusted analysis, LEP patients had lower time in therapeutic range compared with non-LEP patients (OR 1.5, CI [1.1, 2.2]), but were not at greater risk of spending more time the danger range.
[134]Hep B serologic statusretrospective cohort1997–201722,56516,449outpatient health center in New York CitySelf-report of language preference in chart, LEP if other than EnglishMandarin, Cantonese, OtherOverall, LEP status was associated with higher likelihood of HBV current or ever infection. In the multivariate analysis, specifically having Mandarin as a preferred language was associated with higher likelihood of Hep B current infection [OR 1.67 (CI 1.33–2.10)], or ever-infection [OR 1.93 (CI 1.69–2.21)].
[135]Hep B serologic statusretrospective cohort2000–201012341234Outpatient clinic in Seattle, WAPrimary spoken language in medical recordSomali, Amharic,
Khmer, Vietnamese, Tigrinya, Oromo, Chinese, Other
Only 8.9% of the sample was vaccinated. 56% were core positive, meaning they had been exposed to Hep B in their lifetime. There was a higher prevalence of exposure among speakers of Khmer and Oromo.
[136]Treatment adherence for CVD risk factor controlling medicationsretrospective cohort2005131,2776712Kaiser
Permanente Northern California
self-report language preferenceSpanishSpanish-speaking patients were less likely than English speaking patients to be in good adherence (51% versus 57%, p < 0.001). When considered separately adherence for glucose lowering medications, lipid lowering medications, and BP lowering medications also showed a significant difference between Spanish and English speaking patients.
[137]HgbA1c, LDL, BPretrospective cohort2013–201454601555Hennepin County Medical Center (Minneapolis)Preferred language in medical recordSpanish, Somali, Amharic, otherMore LEP patients met BP targets (83 vs. 68%, p = 0.000) and obtained LDL targets (89 vs. 85%, p = 0.000), but this group also had worse LDL control (57 vs. 62%, p = 0.001).
[12]Asthma symptom control (by ACQ score), and service utilization prospective cohort2004–200731857primary care clinics, 1 in East Harlem, NY, and 1 in New Brunswick, NJreport 1) that English was not their native language, and 2) that they could not speak as well as a native speakerSpanishHispanic LEP patients had significantly higher ACQ scores (higher scores mean worse symptom control), at both the 1 month and 3-month follow-ups, with the most striking difference at the 3-month follow-up. This finding remained significant even after participants over 65 were excluded from the sample, and remained significant in the multivariate analysis. LEP patients also had significantly more exacerbations requiring inpatient follow-up, again even when controlling for age (p < 0.05 for all comparisons).
[13]Asthma symptom
control (by ACQ score), and service utilization
prospective cohort2009–201126838Outpatient clinics in NYC and ChicagoSelf-report of speaking
English “very poorly,” “poorly” or “fairly” on initial study interview
SpanishHispanic LEP patients had worse asthma control (p = 0.0007) and increased likelihood of inpatient visits (p = 0.002). The finding persisted when results were adjusted for demographics, asthma history, comorbidities, depression, and health literacy.
[138]Short-term clinical outcomes after surgery: LOS, mortality, any complication, and disposition to rehab cross-sectional2009–20177324554New Jersey
inpatient neurosurgery wards
primary language recorded on admission was not EnglishSpanish, otherThe non-Spanish-speaking LEP group had increased post-operative LOS (adjusted incidence rate ratio, 1.10; p = 0.008) and higher odds of a complication (adjusted OR, 1.36; p = 0.015).
NA means not available in the published manuscript. Abbreviations used in the table include the following: LEP, limited English proficiency; EP, English proficient EHR, electronic health record; LOS, length of stay; BP, blood pressure.

3.5. General Health Outcomes

There were 17 studies that looked at general health status. Of these, one looked at oral health [3], ten looked at mental health [2,21,141,142,143,144,145,146,147,148], twelve looked at general health status [2,21,141,142,143,144,145,146,147,148], and four looked at physical functioning [142,144,145,147]. The majority of the studies looked at Asian-language LEP populations, including Chinese, Korean, Khmer, Vietnamese, and Tagalog, while five included Spanish speakers, one looked at Somali, and one looked at Marshallese speakers. Most studies of general health outcomes used self-reported measures, although a few used validated measures of physical and mental functioning, and all of the studies used cross-sectional data. The sample sizes are generally larger than seen in many of the other studies of LEP populations due to the use of national and state surveys, with the largest sample size of 51,048 (LEP 3715) in an analysis of the California Health Interview Survey. The studies mainly reported on outcomes in traditional immigrant-receiving states such as California, Texas, and New York, although there were two smaller surveys conducted in the Midwest [143,149]. Self-reported health questions based on a 5-item Likert scale are common in many cross-sectional surveys, and other large surveys used included the Study of Older Korean Americans, the National Latino and Asian Americans Study, and the New Immigrant Survey. The quality of eight of the studies was low due to restricted geographic regions or sub-analyses that limited sample sizes and impacted generalizability, as well as limited variables to address potential confounding factors, such as those related to socio-economic status, or in one case, language groups.
Having LEP was significantly associated with having fair or poor health compared to the English-proficient population in almost all studies. This also held true for mental health, where individuals with LEP were more likely to report poor mental health, mental distress, and depression than their non-LEP counterparts. In one study, the unadjusted models showed higher mental health status and lower physical health status for LEP populations compared to EP populations, but when the model was adjusted for sociodemographic variables, there was no significant relationship between LEP and mental or physical health outcomes [147]. The study by Takeuchi et al. showed that LEP men were significantly more likely to have lifetime and past-year diagnoses of depression, anxiety, and other psychiatric disorders, but that there was no significant difference in mental health diagnoses between women with LEP and those who were EP [141]. Three studies looked at activity limitations and rates of disability, and all three found that rates were higher in the LEP population, although rates of disability by LEP status differed by language group [21,144,145]. While the overall impacts on both physical and mental health outcomes for the LEP population seem clear, it is important to keep in mind that these outcomes may not be uniform across demographic and linguistic groups and that the LEP population is not monolithic. Please see a list of studies included in this category with key summary information in Table 7 below.
Table 7. General Health Outcome Study Details.
Table 7. General Health Outcome Study Details.
General Health Outcomes
Health OutcomeStudy DesignStudy PeriodTotal Sample Size
(N =)
LEP Sample Size
(n = )
SettingLEP DefinitionLanguagesStudy Outcomes (LEP Related)
[143]mental health (general
distress, somatic distress, and performance distress)
centers and Buddhist temple in Midwest
English language
proficiency measures on a Likert scale of 1 (very poor to 5 (excellent)
VietnameseWomen who reported poorer English language proficiency had greater general distress and somatic distress compared to women with higher English proficiency.
[42]Self-rated overall health statuscross-sectional2014342286CaliforniaParticipants who
reported less
than ‘very well’ to the question—“Would you
Korean or otherLEP participants were 4.67 times more likely to rate their overall health as fair/poor compared to their EP counterparts (CI 1.25–16.40, p< 0.05). Data on physical activity and smoking status were not significant.
[148]self-rated general health, mental distress, and cognitive healthcross-sectional2017–201820321512Los Angeles, CA;
New York City, NY; Austin, TX, Honolulu, HI;
how well participants spoke English, not at all/a little)KoreanLEP was a significant predictor in the model for self-rated health (OR = 1.99, CI = 1.37, 2.87) and mental distress (OR = 1.43, CI = 1.04, 1.96), but not for cognitive health
[145]activity limitation, self-rating of general health, and symptoms of depressioncross-sectional2008–20131301922FL, NY, and TXreported that they spoke
English less than very well
KoreanLEP significantly increased the odds of an activity limitation (OR = 2.72 ), fair or poor heath (OR = 2.59), and probable depression (OR = 1.73) compared to non-LEP.
[146]self-reported mental healthcross-sectional2002–2003865481NationalLanguage of interviewSpanishLEP had statistically significant worse (RR = 2.12) mental health with no psychosis
[21]physical and mental health statuscross-sectional20071745988CaliforniaReported English speaking ability was not well or not at allSpanish, Korean, Mandarin, Vietnamese, and CantoneseOf the four chronic health conditions studied, diabetes mellitus was the only condition that was significantly different across language groups for Latinos (LEP 27.2%, EP 18.6%, English Only [EO] 13.2%). Rates of chronic health conditions did not differ according to language status for Asian immigrants. Disability rates were significantly higher in Latinos and Asians with LEP than in their counterparts with EP and EO. Individuals with LEP had poorer self-rated physical and mental health compared to both EP and EO immigrants.
[150]Self-rated overall health statuscross-sectional2010381137 do not
speak English; 239 prefer to have an interpreter
community coalition in Lowell, MADo not Speak English;
Prefer to have an interpreter in healthcare settings; prefer to
KhmerIn bivariate analysis, Speak English (OR= 3.3) and prefer to receive health information in English (OR = 1.96) are more likely to have excellent, very good, or good self-reported health. Prefer to have an interpreter in healthcare settings are less likely (OR = 0.38) to have excellent, very good, or good health. In the multivariate analysis, LEP was not a significant predictor of self-reported heath after taking age, sex, and disability into account.
[149]Self-rated overall health statuscross-sectionalNA37879Diabetes
Prevention Program in Arkansas and Oklahoma
individual reported speaking English not well or not at allMarshalleseRegression analysis showed that participants who reported speaking English not at all/not well were significantly less likely to report better general health (excellent health or good health vs. fair/poor health) compared with those who reported speaking English very well (OR = 0.22, CI:.09, 0.54).
[142]self-rated overall
health status, mental health, and physical functioning
cross-sectional2000205NANew York CitySpeaking English proficiency rated as Not at all, Not too well, Some what, or Very wellChinese, KoreanLanguage proficiency predicated variance in physical functioning, general health, and mental health.
[147]Physical and Mental Component Summary Medical Outcomes Study Short-Formcross-sectional2009–2011439293Massachusettsthe Basic English Skills Test Plus (BEST Plus) low proficiency (0–329), moderate
proficiency (330–598)
SomaliHaving low English proficiency (β = 1.75, p = 0.02) were associated with higher mental health scores in the unadjusted model but had no significant relationship in the adjusted model. Low English proficiency were significantly associated with lower physical health scores in the unadjusted β = −3.33, p < 0.00) but not the adjusted models. No impact of moderate proficiency was found.
[144]self-rated overall
health status, mental health, and physical functioning
cross-sectional20051196NACaliforniaEnglish proficiency from “only English” (1) to “not at all” (5).NALower levels of English proficiency were associated with higher odds of reporting worse General Health [OR = 1.85 (1.56, 2.19)], more Limited Physical Days [OR = 1.23 (1.02, 1.49)], and more Limited Combined (mental and Physical Health) Days [OR = 1.23 (1.03, 1.47)].
[151]Self-rated overall health statuscross-sectional2003–2004763148Nationalself- rated respondents spoke English- ‘‘not well/ not at all’’NALogistic regression showed that those who spoke English very well had lower odds of rating their current health as good/fair/poor than those who did not speak English well/not at all.
[2]Self-rated overall health status and mental healthcross-sectional200118,0001242Californiareported speaking English not well or not at allSpanish, Cantonese,
Korean, Vietnamese, and Khmer,
In bivariate analysis LEP older adults had significantly higher proportions that reported poorer general and emotional health status than older adults who speak English only. In multivariate analysis, LEP older adults had increased risk of being in fair or poor health (RR = 1.68, p < 0.001) and of feeling sad all or most of the time (RR = 2.49, p < 0.001) compared with English only speakers.
[152]Self-rated overall health statuscross-sectional200751,0483715CaliforniaSelf-reporting speaking English “not well” and “not at all.”Spanish, Mandarin, Cantonese, Korean, and
LEP pop were significantly more likely to report poor health status compared to those with English proficiency (42.9% vs. 14.9%). Compared to those with English proficiency and adequate health literacy, the odds ratios of poor health were 2.10 (CI: 1.70–2.58) for LEP. LEP was also significantly associated with poorer health status vs. the reference among Latinos (OR: 2.01; CI: 1.51–2.69), Vietnamese (OR: 5.46; CI: 2.47–12.05), Whites (OR: 2.05; CI: 1.03–4.08), and Other race/ethnicity (OR: 2.05; CI: 1.34–3.12).
[3]oral healthcross-sectional20081870231New York CitySelf- reported ability to speak English was poorChinese, SpanishAmong Chinese group, those who reported that their ability was fair or better were 2.24 (1.02, 4.96) more likely, (compared to Chinese spoken English poor) to have gone to a dentist in the past year. Difference among Hispanic LEP group was non-significant.
[141]lifetime and 12-month rates of any depressive, anxiety, and substance abuse disorderscross-sectional2002–20032095797National studyIndividual reported that spoken English was “fair/poor.”English, Spanish, Mandarin, Cantonese, Tagalog, and VietnameseIn the regression analysis non-LEP men were significantly less likely than LEP men to have any lifetime (OR = 0.44) or 12 month (OR = 0.29) depressive disorder, lifetime (OR = 0.51) or 12 month (OR = 0.45) anxiety disorder, or lifetime (OR = 0.52) or 12 month psychiatric disorder (OR = 0.45). There was no significant difference in mental health diagnoses between women with LEP and those who were English proficient.
[153]Self-rated overall health statuscross-sectional2010–2013705self-rated
English proficiency—473; ever need medical interpreter—244
San Francisco, CAself-rated spoken English proficiency (“not at all,” “poorly,”) or ever having need for medical interpretation at their doctor’s officeCantonese, MandarinSpeaking English “poorly” or ‘not at all,’ was significantly associated with
poor self-rated health in regression models. The need for a medical interpreter was not associated with self-rated health.
NA means not available in the published manuscript. Abbreviations used in the table include the following: LEP, limited English proficiency; EP, English proficient.

4. Discussion

Our comprehensive review of 137 studies on the impact of LEP on healthcare outcomes reveals nuanced patterns across different healthcare settings and conditions. The diversity in study design, participant demographics, and outcome measures necessitates a careful interpretation of findings and highlights the complexities of addressing healthcare disparities among LEP populations. The lack of standardized definitions for LEP and variations in healthcare settings may contribute to inconsistencies in reported outcomes.
The majority of these studies had small LEP sample sizes and considerable variability in defining the LEP population. One of the difficulties our team encountered during searching was the tendency to conflate language interpretation with language translation. Interpretation refers to spoken language, while translation is meant to refer only to written language. However, in practice, these terms are often used interchangeably, and there tends to be some overlap and a lack of precision in their use. In addition, defining LEP varies by type of study and even within type, making it difficult to compare across studies, which may account for differences in outcomes. Studies that included data extracted from electronic health records (EHR) used either the need for an interpreter, which can underreport LEP since not everyone with LEP requests an interpreter, or a flag indicating LEP, which may be inaccurate. A recent study conducted at two hospitals showed positive predictive values as low as 60% for non-English preference in the EHR [154]. Indeed, the study by Balakrishnan et al. found that a significant number of patients who described themselves as Spanish speakers were misclassified as English speakers [75]. In addition, non-native English speakers may have difficulty with medical terminology, creating a language barrier in this particular setting. Issues of misclassification can dilute differences between LEP and EP populations, attenuating what may be potentially significant associations. Studies that included surveys generally used self-report or the language of the survey to determine LEP. Since surveys are often available in limited languages, this can restrict the LEP populations that we can assess for healthcare access and outcomes. Notably, Spanish was overwhelmingly the most studied language group, emphasizing the need for more inclusive language representation in future research.
The reliance on retrospective chart reviews and cross-sectional designs limits causal inference and underscores the need for prospective and experimental studies. The preponderance of observational studies is understandable, given the complexities and institutional resource demands associated with quasi-experimental and experimental studies. However, the observational nature of these studies limits our ability to establish causal relationships and may introduce confounding variables that independently influence outcomes and are not controlled for in the studies. We saw this in differential outcomes by language group and biological sex, and after modeling, we controlled for socio-demographic characteristics like health insurance and education that may be linked to both immigrant and LEP status. An example of this can be found in the ambulatory care results for the Pylypchuk and Hudson study, which showed differential access to ambulatory care by insurance status [30]. Many studies, particularly those focusing on hospital-based treatments and surgeries, had relatively small LEP patient sample sizes. This limits the generalizability of findings and underscores the importance of conducting studies with larger, more diverse populations to enhance the external validity of the results. The studies covered a spectrum of chronic and acute health issues and settings, ranging from diabetes to mental health conditions and even surgical outcomes. While this diversity enriches our understanding of health disparities, it complicates the task of drawing generalizable conclusions. The varying benchmarks across conditions and healthcare modalities make it challenging to create a unified framework for assessing outcomes, emphasizing the need for interpretations that take into account potential confounding variables.
Importantly, the overall results on healthcare access and outcomes showed that LEP populations experience disparities in access and outcomes across both ambulatory and acute care, as well as in specific condition outcomes and general physical and mental health outcomes:
  • Ambulatory care studies generally showed that the LEP population was less likely to have a usual source of care and had fewer ambulatory care visits.
  • In the hospitalization studies, 30-day readmission was clearly higher for LEP populations, which dovetails with the studies that found that LEP patients were less likely to receive discharge instructions that they could understand and, therefore, less likely to follow through with discharge instructions.
  • Both the specific condition and general health outcome studies show a pattern of worse outcomes for physical and mental health for LEP populations compared to EP populations.
Particularly interesting areas to focus on for further research are those where studies showed mixed outcomes. This could be due to communication barriers, cultural barriers, socio-economic barriers, or a combination of factors. The impact of LEP on LOS was variable by reason for hospitalization, with increased LOS shown for trauma-related and major surgery hospitalizations, but no differences in LOS were found for other types of hospitalizations. Hospitalization outcomes for specific conditions also showed mixed results on the impact of LEP. This may indicate areas where addressing communication barriers can make a difference in outcomes and cost. Colorectal and cervical screenings generally showed that LEP populations were less likely to be screened, meaning that cancer may be found at a later stage, resulting in poor outcomes. However, mammography screening studies were almost evenly split between no effect of LEP and LEP populations accessing fewer screenings. This is a key area that may allow us to explore differences between language groups and even geographic regions in order to identify what is driving differential outcomes.

5. Limitations

One challenge specific to identifying the literature on LEP populations, as we observed in our review, is that there is wide variability in how LEP is defined and how those definitions are applied. There are also a large variety of disciplines investigating this issue from different perspectives. In an effort to cast a wide net, we included very different types of databases, necessitating some variability in our search strings. We acknowledge that this variability has the potential to introduce selection bias. We additionally elected to focus on spoken language only, which excludes any studies focused primarily on written communication, even if these studies might independently show an impact on LEP health outcomes. We also chose not to focus our searches on other closely related topics we encountered, such as health literacy and language concordance, in order to focus on the impact of spoken language on healthcare outcomes. In our opinion, these limitations only underscore the need for further work in this area.

6. Conclusions

Despite the inherent limitations, these findings underscore the urgent need for targeted interventions and policy initiatives in the U.S. to address disparities in conditions ranging from chronic diseases to surgical outcomes for the LEP population. Future research endeavors should prioritize experimental designs, explore the impact of language concordance and translation services, and strive for larger and more diverse sample sizes to enhance the robustness and generalizability of findings. A key part of this will be the consistent definition and collection of LEP data in both EHRs and surveys. Table 2, which includes publicly available datasets used for LEP access and outcome analysis, can be a first step in increasing research in this area. This review provides a foundation for advancing our understanding of health outcomes in LEP populations. By addressing the identified limitations and building on these insights, researchers can contribute to the development of tailored interventions that mitigate health disparities, ultimately promoting equitable healthcare for all linguistic communities.

Supplementary Materials

The following supporting information can be downloaded at:, Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist. Ref. [155] is cited in Supplementary Materials.

Author Contributions

Conceptualization, S.E.T.; methodology, S.E.T., L.G.-O. and R.J.; validation, S.E.T., R.J., L.G.-O., E.W. and C.P.; formal analysis, S.E.T., R.J., L.G.-O., E.W. and C.P.; data curation, L.G.-O.; writing—original draft preparation, S.E.T., R.J., L.G.-O., E.W. and C.P.; writing—review and editing, S.E.T. and R.J.; visualization, L.G.-O.; supervision, S.E.T. and R.J. All authors have read and agreed to the published version of the manuscript.


This research received no external funding.

Institutional Review Board Statement

Not applicable.

Data Availability Statement

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Conflicts of Interest

The authors declare no conflict of interest.


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Figure 1. PRISMA flow diagram describing the scoping review search for studies examining the impact of limited English proficiency (LEP) on adult healthcare services utilization and outcomes in the U.S.
Figure 1. PRISMA flow diagram describing the scoping review search for studies examining the impact of limited English proficiency (LEP) on adult healthcare services utilization and outcomes in the U.S.
Healthcare 12 00364 g001
Table 1. Search summary table.
Table 1. Search summary table.
DatabaseSearch String and/or StrategyFiltersNumber of Results
PubMed((((limited English proficiency[MeSH Terms]) OR (language barrier[MeSH Terms])) AND ((((hospitalization[MeSH Terms]) OR (delivery of healthcare[MeSH Terms])) OR (quality of healthcare[MeSH Terms])) OR (emergency departments[MeSH Terms]))) AND (united states)) NOT (digital divide[MeSH Terms])English
Exclude preprints
Adult: 19+ years
From 2000 to 2023
Academic Search PremierSU (“limited English proficiency” OR “language barriers”) AND SU (“health services accessibility” OR “health outcome assessment” OR “hospitals” OR “emergency departments”) NOT SU (“digital literacy” OR “digital divide”)SmartText Searching
Source Type(s): Academic Journals and Trade Publications
From 2000 to 2023
CINAHL((((limited English proficiency) OR (language barrier)) AND ((((hospitalization) OR (delivery of healthcare)) OR (quality of healthcare)) OR (emergency departments))) AND (united states)) NOT (digital divide) Basic Search
Source Type(s): Academic Journals and Dissertations
From 2000 to 2023
Sociological Abstracts(“limited English proficiency” OR “language barriers” OR “language proficiency”) AND (health care) Advanced Search
Source Types: Scholarly Journals, Dissertations and Theses, and Other Sources.
United States
From 2000 to 2023
EconLit TX language proficiency AND SU (“health care” OR “health behavior”)English
Source Type(s): Academic Journals and Dissertations
From 2000 to 2023
Table 2. Publicly available datasets with information on LEP used by studies in this scoping review.
Table 2. Publicly available datasets with information on LEP used by studies in this scoping review.
Publicly Available State or National Dataset UsedResearch Focus AreaNumber of Papers Using
American Hospital Association (AHA) Annual SurveyHospital Care1
Asian American Quality of Life SurveyAmbulatory Care1
Behavioral Risk Factor Surveillance System Screening3
California Cancer RegistrySpecific Conditions1
California Health Interview SurveyAmbulatory Care; General Health Outcomes; Screening10
Community Tracking Study Household SurveyAmbulatory Care1
DISTANCE Study Data (Diabetes Study of Northern California)Specific Conditions3
Hawaii’s Health Information Corporation’s Inpatient DatabaseHospital Care1
Hispanic Established Population for Epidemiological Studies of the Elderly (Hispanic EPESE)Specific Conditions2
Los Angeles Latino Eye Study (LALES)Ambulatory Care1
Medical Expenditure Panel SurveyAmbulatory Care2
Minnesota Community Measures registrySpecific Conditions1
National Agricultural Workers Survey (NAWS)Ambulatory Care1
National Consumer Assessment of Healthcare Providers and Systems (CAHPS) Benchmarking Database (NCBD)Ambulatory Care1
National Health and Aging Trends StudySpecific Conditions1
National Health and Nutrition Examination Survey (NHANES) Specific Conditions2
National Health Interview Survey (NHIS)Ambulatory Care2
National Latino and Asian American Household SurveyAmbulatory Care; General Health Outcomes3
National Trauma Registry of the American College of Surgeons (NTRACS)Hospital Care1
New Immigrant SurveyGeneral Health Outcomes1
State Inpatient Database (SID)—New Jersey *Specific Conditions1
State Inpatient Database (SID)—California *Hospital Care1
Study of Women’s Health Across the Nation (SWAN)Screening1
* Currently only 7 states have patient language data available in their SID.
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Twersky, S.E.; Jefferson, R.; Garcia-Ortiz, L.; Williams, E.; Pina, C. The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review. Healthcare 2024, 12, 364.

AMA Style

Twersky SE, Jefferson R, Garcia-Ortiz L, Williams E, Pina C. The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review. Healthcare. 2024; 12(3):364.

Chicago/Turabian Style

Twersky, Sylvia E., Rebeca Jefferson, Lisbet Garcia-Ortiz, Erin Williams, and Carol Pina. 2024. "The Impact of Limited English Proficiency on Healthcare Access and Outcomes in the U.S.: A Scoping Review" Healthcare 12, no. 3: 364.

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