Immigration, Birth Status Predicts Limited Patient Health Literacy

Limited patient health literacy is 81 percent more common in racial and ethnic minority patients who are also immigrants, according to new UC Irvine data, shedding new light on how health literacy can shape health disparities.

These findings, which the researchers said offer a more nuanced view of how health literacy can differ by population, may help healthcare policymakers better tailor health literacy interventions.

Patient health literacy—defined as the ability to find, understand, and use health information—has a significant impact on patient health. Health literacy is closely intertwined with patient activation and engagement and can translate into better chronic disease management, patient navigation, and outcomes.

But health literacy levels can vary. According to data from the HHS Department of Disease Prevention and Health Promotion, only 12 percent of US adults have proficient health literacy; about a third have subpar health literacy. Black and Hispanic patients are more likely to fall into the “basic” and “below basic” health literacy buckets and less likely to have intermediate or proficient health literacy levels.

But even among those racial and ethnic minorities, there are differences in health literacy levels, this latest study revealed.

The study, published in the Journal of General Internal Medicine, specifically zoomed in on racial and ethnic minority patients and segmented them by birth status, or whether or not the patient is an immigrant.

“This study provides a new perspective on health literacy,” Aryana Sepassi, a study author and UC Irvine assistant clinical professor of clinical pharmacy, said in an emailed statement.

“There are many nuances within groups. We wanted to identify the impact of the differences between immigrant and US-born racial-ethnic minorities, which range from English not typically being an immigrant’s first language to unique cultural values and norms,” Sepassi added. “As healthcare providers, we have the resources to help communicate with these patients, but place too much responsibility on them to understand what we are trying to say, rather than focusing on how we communicate with them.”

Using 2019 data from the Medial Expenditure Panel Survey about more than 81 million people, the researchers concluded that immigration status can heavily influence patient health literacy levels. Across the total study population, 14.3 percent of racial/ethnic immigrants fell into the “below basic” health literacy bucket, compared to 5.5 percent of racial/ethnic minority patients who are not immigrants.

Immigration status had the strongest negative association with health literacy level, with individuals who were also immigrants being more likely to see lower health literacy levels. Immigration status may have been mediated by factors like insurance status, health system utilization patterns, and English language proficiency.

But, overall, racial/ethnic minority patients who were also immigrants had an 81 percent higher prevalence in the “below basic” health literacy category than those who were not immigrants, the researchers reported.

“These results may be indicative of underlying inequities faced by racial/ethnic minority immigrants, which in turn reduce opportunities for achieving crucial factors for development of higher HL proficiency, such as social and economic upward mobility,” they wrote in the study’s discussion section.

For example, Black immigrants are more likely to live below the poverty line than the total US population. Immigrants also see higher unemployment rates than the rest of the US, while Asian and Hispanic immigrants are less likely to have higher educational attainment than the remainder of the US population.

Each of those social determinants of health—income, employment, and education attainment—likely has a downstream effect on patient health literacy, the researchers suggested, and therefore may ultimately impact health outcomes. Future research may focus on each of those pieces individually to better understand their effect on health literacy.

Until then, it would be fruitful to reexamine public policy that may be hampering health literacy levels and other social determinants of health for immigrants. The researchers pointed out that the 1996 Personal Responsibility Work Opportunity Reconciliation Act (PRWORA) restricted immigrant access to certain social safety nets, like Medicaid, which could have downstream impacts on social health factors.

At the health system level, creating more language access programs might be fruitful. Healthcare organizations face federal mandates for language and interpreter accommodations, while health payers must provide certain documents, like explanations of benefits, in multiple different languages. The researchers suggested taking these efforts a step further by tying incentives to language services and health literacy programming.

“We believe that policymakers should implement changes that address the combination of inequities in both the upstream social determinants of health and health policy,” Sepassi concluded in the emailed statement. “To fill these gaps, changes should be implemented that improve access to more equitable health literate services that are specifically targeted to immigrant racial-ethnic minorities.”