Health Literacy Studies: Research Reports

The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy *New posting
The Health Literacy of America’s Adults is the first release of the National Assessment of Adult Literacy (NAAL) health literacy results. The results are based on assessment tasks designed specifically to measure the health literacy of adults living in the United States. Health literacy was reported using four performance levels: Below Basic, Basic, Intermediate, and Proficient. Relationships between health literacy and background variables (such as educational attainment, age, race/ethnicity, where adults get information about health issues, and health insurance coverage) were also examined and reported.

Literacy and Health in America
The report, Literacy and Health in America, is the third in a series of reports using information collected from existing surveys, the National Adult Literacy Survey (NALS) and the International Adult Literacy Survey (IALS), conducted by ETS for the U.S. Department of Education. The authors, Rima Rudd of Harvard School of Public Health, and Irwin Kirsch and Kentaro Yamamoto of ETS, identified 191 health-related tasks among the survey data and analyzed health literacy of U.S. adults.

The researchers found that some 12 percent or 23 million of U.S. adults are estimated to have skills in the lowest level (Level 1) on the HALS, while an additional 7 percent or 13.4 million are not able to perform even simple health literacy tasks with a high degree of proficiency (below Level 1). Those performing below Level 1 are about evenly divided between U.S.-born and foreign-born adults.

Results are alarming for at-risk and vulnerable populations. For example, among adults who have not completed high school, almost half scored at or below the lowest literacy level. Similarly, almost half of adults over the age of 65 performed at or below the lowest level. Minority populations, including adults born outside the United States, scored significantly below white adults and adults born in the United States, on average.

Health Literacy: A Prescription to End Confusion
The Institute of Medicine, National Academies of Science, impaneled a Committee on Health Literacy. Rima Rudd served on that committee. The report, Health Literacy: A Prescription to End Confusion, defines health literacy and its scope, identifies obstacles to creating a health literate public, assesses the approaches that have been attempted to increase health literacy, and identifies goals for health literacy efforts as well as key players who may contribute to these goals.

Literacy and Health Outcomes
The report, Literacy and Health Outcomes, from the Agency for Healthcare Research and Quality offers a systematic review of healthy literacy outcome studies published between 1980 and 2003. The authors assessed published studies with the following key questions in mind:

[1] What is the relationship between literacy skills and use of health care services, health outcomes, health care costs, and/or disparities?

[2] What, if any, effective interventions have been identified to improve use of services, improve health outcomes, reduce costs, and/or reduce disparities?

The authors conclude that low literacy, as measured by reading skills, is associated with several adverse health outcomes, including low health knowledge, increased incidence of chronic illness, poorer intermediate disease markers, and less than optimal use of preventive health services. Interventions to mitigate the effects of low literacy have been studied, and some have shown promise for improving patient health and receipt of health care services. Future research, using more rigorous methods, is required to better define these relationships and to guide development of new interventions.

Communicating Health: Priorities and Strategies for Progress
Action Plans To Achieve the Health Communication Objectives in Healthy People 2010
The purpose of the action plans is to focus the attention of researchers, teachers, practitioners, policymakers, and organizations on the general strategies and specific steps that they can take in support of the objectives. In general, the strategies and action steps aim to raise awareness, generate new information, stimulate funding and innovative policies, promote evaluation, and encourage development of programs and interventions that support progress toward the targets for each objective. The action plans are not intended to be definitive in their current form. They are works in progress and will be reviewed and updated as needed.

Objective 11-2. Improvement of Health Literacy
All of the proposed strategies and solutions depend on building increased awareness of the magnitude of health literacy problems in the United States and on identifying systemic changes that will make U.S. health systems easier for individuals to understand and use. A critical link among literacy, health, and health status must be recognized at a broad societal level. Ensuring health literacy in the United States is a fundamental issue of fairness and basic human rights.

Health Literacy: Responding to the Need for Help, by K.M. Kiefer. Center for Medicare Education; February 2001.
The author offers an overview of health literacy with specific attention to health and literacy concerns of elders. This report also focuses on innovative programs throughout the country that address the needs of people with limited literacy related to health activities. The overview of programs highlight specific approaches that various hospitals, clinics and learning centers are using to identify and assist adults with limited literacy skills. Included are one-on-one assistance, group assistance, visual tools and training programs. The report also includes guidelines for program managers to consider as they initiate and sustain health literacy efforts.

At Risk: A Socio-economic Analysis of Health and Literacy Among Seniors, by P. Roberts and G. Fawcett. Ottawa, Ontario: Statistics Canada; 1998.
This report offers a critical analysis of the links between health and socioeconomic factors and the links between health and literacy. The author focuses on health and literacy issues for elders and analyzes the results of the International Adult Literacy Survey (IALS), conducted in Canada. Findings indicate that many elders with low literacy skills are unable to consistently perform literacy tasks, that they tend to over-estimate their literacy abilities, and that they may not ask for assistance. Authors conclude that many health problems faced by elders are exacerbated by low literacy skills.

This section of the Health Literacy website highlights Adult Literacy Research and Policy Reports.

The International Adult Literacy Survey (IALS): Understanding What Was Measured, by I. Kirsch. Educational Testing Services, Center for Global Assessment; December, 2001. This paper provides a thorough explanation of the framework used to develop the tasks on the IALS. The framework is comprised of six parts: Defining Literacy, Organizing the Domain, Task Characteristics, Identifying and Operationalizing Variables, validating Variables and Building an Interpretive Scheme. The author provides a clear explanation of regression analyses that identify and verify variables associated with performance on the literacy tasks in the IALS.

The Twin Challenges of Mediocrity and Inequality: Literacy in the U.S. from an International Perspective, by A. Sum, I. Kirsch and R. Taggart. Educational Testing Services, Statistics and Research Division; Center for Global Assessment; February, 2002. This paper compares the US results on the IALS with the results of 20 other industrialized nations. The performance of all US adults on the NALS/IALS assessment can be described as “average” for the participating high-income countries. The results were broken down by age, gender, race/ethnicity, and native vs. foreign born. Some key findings include:

All groups of young adults in the US had average proficiencies below those of their counterparts with comparable amounts of schooling and living in high income countries.

The U.S. data indicates a greater disparity among population groups than is found in other countries.

NALS assessment revealed that 71%-85% of the nation’s adults 65 and older had only Level 1 or Level 2 proficiency on each of the three literacy scales.

The mean scores of members of minority population groups in the US were in the range of 43 to 75 points below those of Euro-Americans.

The authors argue that if we fail to reduce the degree of inequality in literacy skills over the coming decade, then the cognitive demands for access to most high-skilled, high wage jobs in US labor markets and for active participation in civic and political life will create an unequal divide in the distribution of economic and political rewards in the future. Additionally, the nation’s changing demographics will likely exacerbate the literacy skill deficit in the coming years since most of the fastest-growing population groups are those with below-average skills.

Benchmarking Adult Literacy in America: An International Comparative Study, by A. Tuijnman. U.S. Department of Education; September 2000. The author compares findings from the National Adult Literacy Survey (NALS) conducted in the U.S. in 1992, with findings from the International Adult Literacy Survey (IALS), conducted in 22 industrialized countries between 1994 and 1998. The analysis focuses on 10 indicators that allow the reader to compare prose literacy skills of adults in the U.S. with those of adults in other countries. Analyses indicate that U.S. adults score in the mid-range of prose literacy scores. However, the U.S. NALS findings indicate a larger disparity among various population groups than is found in other countries. The author suggests that policy makers use “life-long learning” as a framework for improving literacy in the U.S. and offers 10 specific targets and tools for improving literacy.

Adult Literacy in America: The First Look at the Results of the National Adult Literacy Survey (NALS), by I. Kirsch, A. Jungeblut, L. Jenkins and A. Kolstad. Washington, DC: U.S. Department of Education; 1993.

NALS - Major Findings: The NALS provides a profile of the English literacy of U.S. adults, based on their performance on varied tasks that represent materials used and skills needed in everyday life. In 1992, interviews were conducted with over 26,000 individuals, aged 16 and over. Proficiency scores were calculated on three scales: prose, document and quantitative literacy.

NALS results suggest that 21 to 23 percent, or about 20 percent of the total population, demonstrated skills in the lowest level (Level 1) of prose, document and quantitative literacy. About 25 to 28 percent of respondents scored in Level 2 on each of the literacy scales, representing about 50 million adults across the nation.

Literacy Behind Prison Walls, by Haigler, Karl O., Caroline Harlow, Patricia O'Connor, et al., U.S. Department of Ed., NCES, Washington, DC, 1994. The NALS evaluated a sample of inmates in federal and state prisons. Results showed that the demographic characteristics of this population were different than those for the entire population. Inmates tended to be younger and less educated than the average adult. According to NALS, only 20 percent of inmates reported that they completed some post-secondary education. 94 percent of inmates were male, as opposed to 48 percent of the general adult population. Individuals in prisons were also different racially/ethnically than the general population, with Black, Hispanic and American Indian/Alaskan Natives being over-represented in the prison population. Incarcerated individuals were much more likely than adults in the total population to score in lower levels on all three literacy scales. The percentage of the prison population scoring in Level 1 on each scale ranged from 31 to 40 percent, compared to 21 to 23 percent in the average adult population. The percentage of the prison population scoring in Levels 4 and 5 varied from 4 to 7 percent, compared to 18 to 21 percent in the total population.

Literacy of Older Adults in America: Results from the National Adult Literacy Survey, by Brown, Pristuta, Jacobs and Campbell. Washington, DC: U.S. Department of Education; 1996.
More than 1 in 8 Americans are age 65 or older. In order to respond to the literacy needs of older adults in America, the NALS examined the literacy proficiencies of adults age 60 and over. Results of the NALS indicate that low literacy levels are a large problem for many older adults in the U.S. 71 percent of older adults scored in the lowest two levels of prose literacy and 68 percent in the lowest levels of quantitative literacy. Four out of five older Americans demonstrated difficulty in document literacy, scoring in the lowest two Levels. Analysis indicates that skill levels differ by income. The NALS analysis also indicates that many older adults do not believe they have a problem with literacy. While many elders reported receiving help with forms, math and writing letters, the number of adults who receive help is much lower than the number who appear to need assistance.