How limited english proficiency impacts patient engagement with telemedicine: a systematic review – Nature

Report on Telemedicine Disparities and Sustainable Development Goals

Executive Summary

This report summarizes a systematic review of 17 studies examining telemedicine utilization by patients with Limited English Proficiency (LEP) compared to English Proficient (EP) patients in the United States. The findings reveal significant disparities that undermine progress towards key Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being) and SDG 10 (Reduced Inequalities). The analysis shows that LEP patients have significantly lower overall utilization of telemedicine, are less likely to use telemedicine over in-person visits, and have critically lower rates of using video-based telemedicine. These disparities highlight a digital divide that challenges the equitable infrastructure goals of SDG 9 (Industry, Innovation, and Infrastructure). To align the expansion of telemedicine with the 2030 Agenda, this report recommends targeted interventions to address technology access, digital literacy, healthcare system preparedness, and the accessibility of professional interpreters.

Introduction: Telemedicine’s Role in Sustainable Development

The rapid adoption of telemedicine, particularly since the COVID-19 pandemic, represents a significant innovation with the potential to advance SDG 3 (Good Health and Well-being) by improving healthcare access. This technological progress aligns with SDG 9 (Industry, Innovation, and Infrastructure), which calls for building resilient infrastructure and fostering innovation. However, the benefits of telemedicine have not been distributed equally, raising concerns that this innovation may exacerbate existing health disparities and hinder progress on SDG 10 (Reduced Inequalities). This report analyzes these disparities by focusing on the experiences of LEP populations in the United States, a group of over 25.7 million individuals who already face substantial barriers to healthcare. Failure to ensure equitable access for this vulnerable group contradicts the foundational principle of the SDGs to “leave no one behind.”

Methodology of the Systematic Review

This report is based on a systematic review conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

Search Strategy and Selection

• Four databases (CINAHL, EMBASE, PubMed, and Scopus) were searched for peer-reviewed studies published between January 2019 and May 2025.
• Studies were included if they were conducted in the U.S. and compared telemedicine utilization between adult LEP and EP patients.
• An initial search yielded 983 records, from which 17 studies were selected for inclusion in the final analysis.

Quality Assessment

The overall quality of the evidence from the included studies was rated as low to moderate, primarily due to their observational and retrospective designs. This limitation underscores the need for more robust research in this area.

Key Findings: Disparities in Telemedicine Utilization

The review categorized findings into three outcome areas, each revealing significant inequalities that challenge the achievement of universal health coverage (SDG 3) and equality (SDG 10).

Outcome 1: Overall Telemedicine Utilization

This outcome measures direct access to innovative healthcare delivery, a key component of SDG 3 and SDG 9. The findings indicate a significant gap in achieving equitable access for all.

• Five out of seven studies reported significantly lower overall telemedicine utilization among LEP patients compared to their EP counterparts. This disparity represents a direct failure to ensure equal access to healthcare services as mandated by SDG 10.
• A national study found that LEP patients had 20% lower odds of having any telemedicine visit.
• Disparities were consistent across various clinical settings, including primary care, rheumatology, and oncology, indicating a systemic issue.

Outcome 2: Telemedicine Utilization Compared to In-Person Visits

This comparison assesses whether telemedicine is effectively supplementing traditional care for all population groups, a crucial factor in building resilient and inclusive healthcare systems (SDG 3).

• Five of the seven studies in this category found that LEP patients had significantly lower odds of choosing telemedicine over in-person care.
• This trend suggests that the benefits of telemedicine—such as reduced travel time, lower costs, and minimized exposure to infectious diseases—are not being realized equally, thereby perpetuating the inequalities that SDG 10 aims to eliminate.
• Patients documented as requiring an interpreter had particularly low odds of using telemedicine, highlighting the critical role of language support.

Outcome 3: Video vs. Telephone Modality for Telemedicine

The modality of telemedicine used is a critical indicator of access to quality digital health infrastructure (SDG 9), as video visits offer superior clinical value compared to audio-only consultations.

• All seven studies analyzing this outcome found that LEP patients used video telemedicine significantly less than EP patients.
• This “modality divide” is a stark manifestation of the digital divide, forcing a vulnerable population to rely on a lower standard of care. This exacerbates health inequities (SDG 10) and limits the potential of technology to improve health outcomes for all (SDG 3).
• The consistent preference for telephone visits among LEP patients was linked to barriers such as lack of video-compatible devices, unreliable internet access, low digital literacy, and a lack of integrated interpreter services on video platforms.

Discussion: Implications for Sustainable Development

The findings of this review demonstrate that the expansion of telemedicine, while a promising innovation under SDG 9, has inadvertently widened the gap in healthcare access, creating a digital-driven disparity that directly contravenes SDG 10 (Reduced Inequalities). The underutilization of telemedicine, especially high-quality video visits, by LEP patients points to systemic barriers that prevent the realization of SDG 3 (Good Health and Well-being) for this population. These barriers include a lack of equitable access to technology, insufficient digital literacy, and inadequate language support within healthcare systems. Addressing these issues is not only a matter of health equity but is also essential for building the effective and inclusive institutions promoted by SDG 16 (Peace, Justice and Strong Institutions).

Conclusion and Recommendations for Equitable Telemedicine

To ensure that telemedicine serves as a tool for advancing, rather than hindering, the Sustainable Development Goals, it is imperative to address the systemic barriers faced by patients with limited English proficiency. The current trajectory risks deepening health inequities, undermining the core principles of SDG 3 and SDG 10.

Strategic Recommendations

The following actions are recommended to foster a more inclusive and equitable virtual healthcare system that aligns with the 2030 Agenda for Sustainable Development:

1. Enhance Technological Access and Digital Literacy (SDG 9 & 10): Develop and fund programs that provide LEP patients with affordable access to internet services and video-capable devices. Implement digital navigator programs to offer language-concordant training and technical support for using telehealth platforms.
2. Strengthen Healthcare System Preparedness (SDG 3 & 16): Design telemedicine platforms with multilingual interfaces and user-friendly features. Healthcare systems must re-engineer clinical workflows to seamlessly integrate professional interpreter services into both video and audio appointments from the outset.
3. Ensure Adequate Interpreter Accessibility (SDG 10 & 16): Invest in expanding the availability of professional medical interpreters trained for virtual care. Establish and enforce clear institutional policies and provide training for providers on when and how to engage interpreter services to ensure high-quality, language-appropriate care.
4. Promote Inclusive Research and Policy (SDG 10): Standardize the definition and data collection related to language preference and proficiency in health records and research. Future policies on telemedicine reimbursement and regulation must include explicit provisions for language access to prevent the further marginalization of linguistically diverse communities.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

• SDG 3: Good Health and Well-being

  The article directly addresses health equity and access to healthcare services. It examines how the expansion of telemedicine, a key component of modern healthcare delivery, is not reaching all populations equally. The disparities in telemedicine utilization between Limited English Proficiency (LEP) and English Proficient (EP) patients highlight a significant barrier to ensuring healthy lives and promoting well-being for all, as unequal access can lead to poorer health outcomes for vulnerable groups.

• SDG 10: Reduced Inequalities

  This goal is central to the article’s theme. The systematic review focuses on identifying and quantifying inequalities in healthcare access based on language proficiency. The findings, such as “significantly lower utilization for patients with LEP than those with EP,” directly point to inequalities within the U.S. healthcare system. The article’s purpose is to synthesize evidence on these disparities to “inform health policies and practices that support equitable telemedicine delivery,” aligning with the goal of reducing inequalities.

• SDG 9: Industry, Innovation, and Infrastructure

  The article connects to this SDG by discussing the “digital divide” and the role of technology and infrastructure in accessing healthcare. Telemedicine is an innovation that relies on technological infrastructure. The article notes that barriers for LEP patients include “access to technology, digital literacy,” and “lack of internet access, video-compatible devices.” This highlights that without inclusive and accessible infrastructure, technological innovations like telemedicine can exacerbate rather than reduce inequalities.

2. What specific targets under those SDGs can be identified based on the article’s content?

• Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

  The article’s core focus is on the unequal access to telemedicine, which is an essential healthcare service, particularly since the COVID-19 pandemic. The finding that “LEP patients experience existing disparities in healthcare, such as lower access to preventive services, fewer visits to the doctor, and more frequent hospital stays” demonstrates a failure to provide universal access. The lower utilization of telemedicine by this group further impedes progress toward this target.

• Target 10.2: By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status.

  The article highlights the exclusion of LEP patients—a group defined by linguistic status—from the full benefits of digital health innovation. The systematic review’s conclusion that “patients with LEP were less likely to have used telemedicine” shows a lack of inclusion in a critical aspect of the modern healthcare system. The discussion on the need for “adequate interpreter accessibility” and addressing “language barriers” directly relates to promoting the inclusion of linguistically diverse populations.

• Target 10.3: Ensure equal opportunity and reduce inequalities of outcome, including by eliminating discriminatory policies and practices and promoting appropriate legislation, policies and action in this regard.

  The disparities in telemedicine use represent an inequality of outcome in healthcare access. The article notes that “increased use of telemedicine may unintentionally exacerbate inequities in healthcare access.” By identifying these disparities, the review calls for policies and actions to ensure equal opportunity for LEP patients to access virtual care, thereby reducing these inequalities.

• Target 9.c: Significantly increase access to information and communications technology and strive to provide universal and affordable access to the Internet in least developed countries.

  While the article is set in the U.S., the principle of this target is highly relevant. The article identifies the “digital divide” as a key barrier, citing factors like “lack of internet access, video-compatible devices, and digital literacy” as reasons for lower video telemedicine use among LEP patients. This demonstrates that even in a developed country, universal access to technology is not a given and is a prerequisite for equitable access to digital services like telemedicine.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Yes, the article provides several quantitative indicators used in the reviewed studies to measure the disparities in telemedicine access and utilization.

• Overall Telemedicine Utilization Rate (disaggregated by language proficiency)

  This is a primary indicator used throughout the article. Progress can be measured by comparing the rate of telemedicine use between LEP and EP patients. The article states, “five out of seven studies analyzing overall utilization of telemedicine, five reported significantly lower utilization for patients with LEP than those with EP.” Specific data points, such as odds ratios (e.g., “LEP patients had 20% lower odds of having a telemedicine visit compared to EP patients (aOR, 0.80; 95% CI, 0.66–0.96)”), serve as direct quantitative indicators of this disparity.

• Proportion of Healthcare Visits Conducted via Telemedicine vs. In-Person (disaggregated by language proficiency)

  This indicator measures the modality of care received by different patient groups. The article notes that “five out of seven studies investigating the utilization of telemedicine over in-person visits found lower telemedicine utilization for LEP patients.” This comparison helps quantify the extent to which LEP patients are integrated into virtual care models versus relying on traditional in-person visits.

• Utilization Rate of Different Telemedicine Modalities (Video vs. Telephone) (disaggregated by language proficiency)

  This indicator measures the quality and type of telemedicine being accessed, which is a proxy for digital literacy and access to technology. The article consistently finds that “All seven studies analyzing telemedicine utilization by modality found significantly lower video use for patients with LEP than those with EP.” Specific odds ratios are mentioned, such as LEP patients having lower odds of using video visits (OR, 0.52; 95% CI, 0.46–0.59), providing a clear metric for the digital divide in healthcare.

• Availability and Use of Professional Interpreter Services in Telemedicine

  While not always quantified as a primary outcome, the need for and use of interpreters is a critical implied indicator. The article mentions that “limited interpreter availability” is a contributing factor to disparities and notes that one study defined LEP status by the “documented need for an interpreter.” Measuring the proportion of telemedicine visits for LEP patients that successfully integrate a professional interpreter would be an indicator of healthcare system preparedness and equitable service delivery.

4. Summary Table of SDGs, Targets, and Indicators

Source: nature.com