the health literacy of america’s adults · the health literacy scale and health literacy tasks...

The Health Literacy ofAmerica’s Adults

Results From the 2003

National Assessment

of Adult Literacy

U.S. Department of Education

NCES 2006–483

The Health Literacy ofAmerica’s Adults

Results From the 2003

National Assessment

of Adult Literacy

SSeepptteemmbbeerr 22000066

Mark KutnerElizabeth GreenbergYing JinChristine PaulsenAmerican Institutes for Research

Sheida WhiteProject OfficerNational Center for Education Statistics

U.S. Department of Education

NCES 2006–483

UU..SS.. DDeeppaarrttmmeenntt ooff EEdduuccaattiioonnMargaret SpellingsSecretary

IInnssttiittuuttee ooff EEdduuccaattiioonn SScciieenncceessGrover J. WhitehurstDirector

NNaattiioonnaall CCeenntteerr ffoorr EEdduuccaattiioonn SSttaattiissttiiccssMark SchneiderCommissioner

The National Center for Education Statistics (NCES) is the primary federal entity for collecting, analyzing, and reporting datarelated to education in the United States and other nations. It fulfills a congressional mandate to collect, collate, analyze, andreport full and complete statistics on the condition of education in the United States; conduct and publish reports and spe-cialized analyses of the meaning and significance of such statistics; assist state and local education agencies in improvingtheir statistical systems; and review and report on education activities in foreign countries.

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SSuuggggeesstteedd CCiittaattiioonn

Kutner, M., Greenberg, E., Jin, Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 NationalAssessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, DC: National Center for EducationStatistics.

FFoorr oorrddeerriinngg iinnffoorrmmaattiioonn oonn tthhiiss rreeppoorrtt,, wwrriittee ttoo

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or call toll free 1–877–4ED–Pubs or order online at http://www.edpubs.org.

CCoonntteenntt CCoonnttaaccttSheida White(202) [email protected]

Executive Summary

The 2003 National Assessment of AdultLiteracy (NAAL) assessed the English liter-acy of adults in the United States. Included

in the assessment were items designed to measurethe health literacy of America’s adults. The assess-ment was administered to more than 19,000 adults(ages 16 and older) in households or prisons. Unlikeindirect measures of literacy, which rely on self-reports and other subjective evaluations, the assess-ment measured literacy directly through tasks com-pleted by adults.

The health literacy scale and health literacy taskswere guided by the definition of health literacy usedby the Institute of Medicine and Healthy People2010 (a set of national disease prevention and healthpromotion objectives led by the U.S. Department ofHealth and Human Services).This definition statesthat health literacy is:

The degree to which individuals have thecapacity to obtain, process, and understandbasic health information and services needed tomake appropriate health decisions. (HHS 2000and Institute of Medicine 2004)

These health literacy tasks represent a range of liter-acy activities that adults are likely to face in theirdaily lives. Health literacy is important for all adults.Adults may read an article in a magazine or a pam-phlet in their doctor’s office about preventive healthpractices; they may need to fill a prescription, select

iii

Literacy Levels

Demographic Characteristics

and Health Literacy

Overall Health, Health

Insurance Coverage, and

Sources of Information About

Health Issues

and buy an over-the-counter medication, or under-stand health insurance forms. Parents must managetheir children’s health care, including getting themimmunized, taking them for physicals, and havingtheir illnesses treated. Adult children are often facedwith the responsibility of managing their own par-ents’ health care. Older adults must make decisionsabout Medicare supplementary insurance and pre-scription drug benefits. Adults without medicalinsurance may need to determine whether they, theirchildren, or their parents qualify for any public pro-grams. Adults living in older houses and apartmentsmay need to make decisions about the dangers oflead paint or asbestos. All these activities require, orare facilitated by, the ability to read and understandwritten and printed information.

The health tasks for the 2003 assessment were devel-oped to fit into the NAAL’s prose, document, orquantitative scales but were distinguished from theother tasks on those scales by their health content.

■ The prose literacy scale measured the knowl-edge and skills needed to search, comprehend,and use information from texts that wereorganized in sentences or paragraphs.

■ The document literacy scale measured theknowledge and skills needed to search, compre-hend, and use information from noncontinuoustexts in various formats.

■ The quantitative scale measured the knowledgeand skills needed to identify and perform com-putations using numbers embedded in printedmaterials.

The NAAL health tasks included on the assessmentwere distributed across three domains of health andhealth care information and services: clinical, preven-tion, and navigation of the health system.

This report describes how health literacy variesacross the population and where adults with differentlevels of health literacy obtain information abouthealth issues.The analyses in this report examine dif-ferences related to literacy that are based on self-reported background characteristics among groupsin 2003. This report discusses only findings that arestatistically significant at the .05 level.

Literacy Levels

The National Research Council’s Board on Testingand Assessment (BOTA) Committee on PerformanceLevels for Adult Literacy recommended a set of per-formance levels for the prose, document, and quanti-tative scales.The Committee on Performance Levelsfor Adult Literacy recommended that new literacylevels be established for the 2003 assessment instead ofusing the same reporting levels used for the 1992National Adult Literacy Survey (Hauser et al. 2005).Differences between the 1992 and 2003 levels are dis-cussed by the Committee. Drawing on the commit-tee’s recommendations, the U.S. Department ofEducation decided to report the assessment results byusing four literacy levels for each scale: Below Basic,Basic, Intermediate, and Proficient.

The health literacy tasks were analyzed together andwere used to create a health literacy scale. Eachhealth literacy task was also classified as a prose, doc-ument, or quantitative task and was included on oneof those scales.

The BOTA Committee did not recommend per-formance levels for the health scale. Because everyhealth literacy task was included on the prose, docu-ment, or quantitative scale in addition to the healthscale, it was mapped to a performance level (BelowBasic, Basic, Intermediate, or Proficient) on one of thosescales.Tasks were mapped to each scale at the point onthe scale where an adult would have a 67 percent

iv

The Health Literacy of America’s Adults

probability of doing the task correctly. Cut-points forthe performance levels on the health scale were set sothat each task was classified into the same category onthe health scale as on the other scale (prose,document,or quantitative) with which the task was associated.

Demographic Characteristics and HealthLiteracy

■ The majority of adults (53 percent) hadIntermediate health literacy. An additional12 percent of adults had Proficient health litera-cy.Among the remaining adults, 22 percent hadBasic health literacy, and 14 percent had BelowBasic health literacy.

■ Women had higher average health literacy thanmen; 16 percent of men had Below Basic healthliteracy compared with 12 percent of women.

■ White and Asian/Pacific Islander adults hadhigher average health literacy than Black,Hispanic, American Indian/Alaska Native, andMultiracial adults. Hispanic adults had loweraverage health literacy than adults in any otherracial/ethnic group.

■ Adults who spoke only English before startingschool had higher average health literacy thanadults who spoke other languages alone orother languages and English.

■ Adults who were ages 65 and older had loweraverage health literacy than adults in youngerage groups. The percentage of adults in the 65and older age group who had Intermediate andProficient health literacy was lower than the com-parable percentage of adults in other age groups.

■ Starting with adults who had graduated fromhigh school or obtained a GED, average healthliteracy increased with each higher level of edu-cational attainment. Some 49 percent of adultswho had never attended or did not complete

high school had Below Basic health literacy,compared with 15 percent of adults who endedtheir education with a high school diploma and3 percent of adults with a bachelor’s degree.

■ Adults living below the poverty level had loweraverage health literacy than adults living abovethe poverty threshold.

Overall Health, Health Insurance Coverage,and Sources of Information About HealthIssues

■ At every increasing level of self-reported over-all health, adults had higher average health liter-acy than adults in the next lower level.

■ Adults who received health insurance coveragethrough their employer or a family member’semployer or through the military or who pri-vately purchased health insurance had higheraverage health literacy than adults whoreceived Medicare or Medicaid and adults whohad no health insurance coverage. Amongadults who received Medicare or Medicaid,27 percent and 30 percent, respectively, hadBelow Basic health literacy.

■ A lower percentage of adults with Below Basichealth literacy than adults with Basic,Intermediate, or Proficient health literacy gotinformation about health issues from any writ-ten sources, including newspapers, magazines,books or brochures, and the Internet. A higherpercentage of adults with Below Basic and Basichealth literacy than adults with Intermediate andProficient health literacy received a lot of infor-mation about health issues from radio and tele-vision.With each increasing level of health lit-eracy, a higher percentage of adults got infor-mation about health issues from family mem-bers, friends, or coworkers.

v

Executive Summary

Acknowledgments

The National Assessment of Adult Literacy(NAAL) is a complex project whose suc-cessful completion is due to the work of

countless individuals from many organizations.We,at the American Institutes for Research (AIR),especially want to thank the staff at the NationalCenter for Education Statistics (NCES) who havesupported the project. Sheida White, the NAALproject officer, has provided substantive guidanceand direction to all aspects of the assessment. Herintellectual contributions are reflected throughoutthe assessment, analyses, and report. AndrewKolstad, the project’s senior technical advisor andproject officer of the 1992 National Adult LiteracySurvey, provided both technical guidance and aninstitutional memory throughout the project andhelped us reflect on all statistical and technicalissues. Steven Gorman also played a key role inguiding all aspects of the assessment, especially thoserelated to the statistical aspects of the assessment.

Peggy Carr, NCES Associate Commissioner forAssessment, provided the project and team memberswith ongoing support, recommendations, andencouragement.We are very grateful for her leader-ship.William Tirre and Arnold Goldstein of NCESplayed invaluable roles in reviewing the report andguiding it through the review process. Their efforts are very much appreciated. We also thankMarilyn Seastrom, NCES Chief Statistician,and members of the NCES/Education Statistics

vii

Services Institute(ESSI) Technical Review Team,Kevin Bromer, LaTisha Jones, Alison Slade, AparnaSundaram, and Jed Tank, who reviewed the report andmade many suggestions that have improved the finalproduct. Other government reviewers who providedthoughtful comments are Tom Snyder and John Wirt,from NCES, and Cheryl Keenan,Director,Division ofAdult Education and Literacy in the Office ofVocational and Adult Education (OVAE), and RicardoHernandez of OVAE. We also want to thank JalehSoroui of the ESSI for her ongoing substantive contri-butions to the NAAL.Young Chun, Linda Shafer, andAlan Vanneman of National Assessment of EducationalProgress (NAEP)-ESSI reviewed the report and provided important comments and suggestions.

Cynthia Baur, Office of Disease Prevention andHealth Promotion, Office of Public Health andScience, Office of the Secretary of the Departmentof Health and Human Services, played a pivotal rolein conceptualizing, planning, designing, and report-ing on the health literacy component of NAAL.TheNAAL health literacy component is based on herintellectual contributions and perseverance. RonPugsley, former Director of the Division of AdultEducation and Literacy in the Office of Vocationaland Adult Education, played a key role in the earlyplanning stages of the health literacy report. DanSherman from AIR also provided invaluable guid-ance to the health literacy analyses and report.

Our colleagues at Westat, Inc., planned, developed,and implemented the complex sampling and weight-ing necessary for the successful completion of theassessment. Westat also planned and carried out allphases of the data collection, and was responsible fortraining and managing a group of 400 field data col-lection staff.This study could not have been success-ful without the outstanding work of the Westat proj-ect director, Martha Berlin, and the Westat team,including Michelle Amsbary, Leyla Mohadjer, andJacquie Hogan.

Many staff at AIR made substantial contributions tothe health literacy report, often under tight timelines.Stéphane Baldi and Justin Baer, senior members ofthe AIR NAAL team, provided invaluable substan-tive and technical contributions throughout theduration of the project. Bridget Boyle and Yung-chen Hsu conducted analyses for the authors when-ever requested. Rachel Greenberg and ElizabethMoore provided ongoing research and technical sup-port in developing the assessment, preparing the dataand text, and shepherding the report through therevision and review process.

We are especially appreciative of the skills and con-tributions by Holly Baker, who edited the reportthrough multiple revisions, and by Heather Block,who designed and redesigned the report. We aregrateful for their dedication and in awe of their abil-ity to work under often seemingly impossible timeconstraints.Also, Janan Musa provided the AIR teamwith invaluable guidance and administrative andlogistical support throughout the project.

We also want to acknowledge the essential contribu-tions of three other individuals.Archie Lapointe wasan active member of the AIR team during the earlystages of the NAAL, and the project greatly benefit-ed from his experience and wisdom.Another formermember of the AIR team, Eugene Johnson, whodirected the assessment’s psychometrics and prelimi-nary analysis activities, played an essential role in theproject.We also want to acknowledge the contribu-tions of Richard Venezky, who provided invaluableguidance, support, and friendship, and whose memo-ry we cherish.

Thousands of adults participated in the assessment.Their willingness to spend time answering the back-ground questions and assessment items was essentialto ensuring that meaningful data about the literacy ofAmerica’s adults could be obtained.This study wouldnot have been possible without their participation.

viii


Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iiiLiteracy Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

Demographic Characteristics and Health Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Overall Health, Health Insurance Coverage, and Sources of Information About

Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

List of Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiv

Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Defining and Measuring Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Interpreting Literacy Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Conducting the Survey. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Interpretation of Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Cautions in Interpretation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Organization of the Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Chapter 2: Demographic Characteristics and Health Literacy. . . . . . . . . . . . . . . 9Total Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Gender . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Race and Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Language Spoken Before Starting School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Highest Level of Educational Attainment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Poverty Threshold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Chapter 3: Overall Health, Health Insurance Coverage, and Sources ofInformation About Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Self-Assessment of Overall Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Health Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

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CONTENTS

Sources of Information About Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

Appendix A: Sample Health Literacy Assessment Question . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Appendix B: Definitions of All Subpopulations and Background Variables Reported . . . . . . . . . . . . . . . . . . . . . . . .27

Appendix C: Technical Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Appendix D: Standard Errors for Tables and Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

Appendix E: Additional Analyses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

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List of Tables

Table Page

1-1. Overview of the literacy levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

2-1. Average health literacy scores of adults, by language spoken before starting school: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

2-2. Average health literacy scores of adults, by poverty threshold: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

C-1. Weighted and unweighted household response rate, by survey component: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

C-2. Weighted and unweighted prison response rate, by survey component: 2003. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

D2-1. Estimates and standard errors for Figure 2-1. Percentage of adults in each health literacy level: 2003 . . . . . . . . . . . . . . . . . . 40

D2-2. Estimates and standard errors for Figure 2-2. Average health literacy scores of adults, by gender: 2003 . . . . . . . . . . . . . . . . .40

D2-3. Estimates and standard errors for Figure 2-3. Percentage of adults in each health literacy level, by gender: 2003 . . . . . . . . .40

D2-4. Estimates and standard errors for Figure 2-4. Average health literacy scores of adults, by race/ethnicity: 2003 . . . . . . . . . . .40

D2-5. Estimates and standard errors for Figure 2-5. Percentage of adults in each health literacy level, by race/ethnicity: 2003 . . .41

D2-6. Estimates and standard errors for Table 2-1. Average health literacy scores of adults, by language spoken before

starting school: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

D2-7. Estimates and standard errors for Figure 2-6. Average health literacy scores of adults, by age: 2003 . . . . . . . . . . . . . . . . . . . .41

D2-8. Estimates and standard errors for Figure 2-7. Percentage of adults in each health literacy level, by age: 2003 . . . . . . . . . . . .42

D2-9. Estimates and standard errors for Figure 2-8. Average health literacy scores of adults, by highest educational

attainment: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

D2-10. Estimates and standard errors for Table 2-2. Average health literacy scores of adults, by poverty threshold: 2003 . . . . . . . . .43

D2-11. Estimates and standard errors for Figure 2-9. Percentage of adults in each health literacy level, by highest educational

attainment: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

D3-1. Estimates and standard errors for Figure 3-1. Average health literacy scores of adults, by self-assessment of overall

health: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

D3-2. Estimates and standard errors for Figure 3-2. Percentage of adults in each health literacy level, by self-assessment

of overall health: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

D3-3. Estimates and standard errors for Figure 3-3. Average health literacy scores of adults, by type of health insurance

coverage: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

D3-4. Estimates and standard errors for Figure 3-4. Percentage of adults in each health literacy level, by type of health

insurance coverage: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

D3-5. Estimates and standard errors for Figure 3-5. Percentage of adults who got information about health issues from

printed and written media: newspapers, magazines, books or brochures, and the Internet, by health literacy level: 2003 . .45


nonprint media: radio and television, by health literacy level: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46


personal contacts: family, friends, or coworkers; or health care professionals, by health literacy level: 2003 . . . . . . . . . . . . . .46

E-1. Average health literacy scores of adults, by occupational group: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

E-2. Average health literacy scores of adults, by self-assessment of overall health and gender: 2003 . . . . . . . . . . . . . . . . . . . . . . .48

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E-3. Average health literacy scores of adults, by self-assessment of overall health and race/ethnicity: 2003 . . . . . . . . . . . . . . . . .49

E-4. Average health literacy scores of adults, by self-assessment of overall health and age: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . .49

E-5. Average health literacy scores of adults, by self-assessment of overall health and highest educational attainment:

2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

E-6. Average health literacy scores of adults, by type of health insurance coverage and gender: 2003 . . . . . . . . . . . . . . . . . . . . . .50

E-7. Average health literacy scores of adults, by type of health insurance coverage and race/ethnicity: 2003 . . . . . . . . . . . . . . . .50

E-8. Average health literacy scores of adults, by type of health insurance coverage and age: 2003 . . . . . . . . . . . . . . . . . . . . . . . . .50

E-9. Average health literacy scores of adults, by type of health insurance coverage and highest educational attainment:

2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

E-10. Average health literacy scores of adults who got information about health issues from newspapers, magazines,

and books or brochures, by gender: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

E-11. Average health literacy scores of adults who got information about health issues from the Internet, by gender: 2003 . . . .52


and books or brochures, by race/ethnicity: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

E-13. Average health literacy scores of adults who got information about health issues from the Internet, by race/ethnicity:

2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53


and books or brochures, by age: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

E-15. Average health literacy scores of adults who got information about health issues from the Internet, by age: 2003 . . . . . . .54


and books or brochures, by highest educational attainment: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

E-17. Average health literacy scores of adults who got information about health issues from the Internet, by highest

educational attainment: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

E-18. Average health literacy scores of adults who got information about health issues from radio and television,

by gender: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55


by race/ethnicity: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55


by age: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55


by highest educational attainment: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

E-22. Average health literacy scores of adults who got information about health issues from family, friends, or coworkers,

by gender: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

E-23. Average health literacy scores of adults who got information about health issues from health care professionals,

by gender: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56






by age: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57


by age: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58





xiii

Contents

List of Figures

Figure Page

1-1. Difficulty of selected health literacy tasks: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

2-1. Percentage of adults in each health literacy level: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

2-2. Average health literacy scores of adults, by gender: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

2-3. Percentage of adults in each health literacy level, by gender: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

2-4. Average health literacy scores of adults, by race/ethnicity: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

2-5. Percentage of adults in each health literacy level, by race/ethnicity: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

2-6. Average health literacy scores of adults, by age: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

2-7. Percentage of adults in each health literacy level, by age: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

2-8. Average health literacy scores of adults, by highest educational attainment: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

2-9. Percentage of adults in each health literacy level, by highest educational attainment: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . .14

3-1. Average health literacy scores of adults, by self-assessment of overall health: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

3-2. Percentage of adults in each health literacy level, by self-assessment of overall health: 2003 . . . . . . . . . . . . . . . . . . . . . . . . .16

3-3. Average health literacy scores of adults, by type of health insurance coverage: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

3-4. Percentage of adults in each health literacy level, by type of health insurance coverage: 2003 . . . . . . . . . . . . . . . . . . . . . . . . .18

3-5. Percentage of adults who got information about health issues from printed and written media: newspapers,

magazines, books or brochures, and the Internet, by health literacy level: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

3-6. Percentage of adults who got information about health issues from nonprint media: radio and television, by health

literacy level: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

3-7. Percentage of adults who got information about health issues from personal contacts: family, friends, or coworkers;

or health care professionals, by health literacy level: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

xiv


Introduction

Understanding the health literacy of America’sadults is important because so many aspectsof finding health care and health informa-

tion, and maintaining health, depend on understand-ing written information. Many reports have suggestedthat low health literacy is associated with poor com-munication between patients and health careproviders and with poor health outcomes, includingincreased hospitalization rates, less frequent screeningfor diseases such as cancer, and disproportionately highrates of disease and mortality (Baker et al. 1998;Berkman et al. 2004;Gordon et al. 2002;Lindau et al.2001; Rudd et al. 1999; Williams et al. 2002). Lowhealth literacy may also be associated with increaseduse of emergency rooms for primary care (Baker etal. 2004). These findings have implications for thecosts of caring for patients with low health literacy.

As the Committee on Health Literacy of theInstitute of Medicine wrote:

Health literacy is of concern to everyoneinvolved in health promotion and protection,disease prevention and early screening, healthcare maintenance, and policy making.Health lit-eracy skills are needed for dialogue and discus-sion, reading health information, interpretingcharts, making decisions about participating inresearch studies, using medical tools for personalor family health care—such as a peak flow meteror thermometer—calculating timing or dosageof medicine, or voting on health or environmentissues. (Institute of Medicine 2004, p. 31)

1

Defining and Measuring

Literacy

Interpreting Literacy Results

Conducting the Survey

Interpretation of Results

Cautions in Interpretation

Organization of the Report

1CHAPTER ONE

Health literacy is a new component of the 2003National Assessment of Adult Literacy (NAAL).NAAL assessed the English literacy of adults (ages 16and older) in the United States.The assessment wasadministered to more than 19,000 adults (ages 16 andolder) in households or prisons.

This report presents the initial findings on health lit-eracy from the assessment.Analyses presented in thisreport, including those in appendix E, are intendedto provide a summary of the relationship betweenhealth literacy and background characteristics ofadults, preventive health practices, and sources ofhealth information used by adults.

Defining and Measuring Literacy

Defining Literacy

Unlike indirect measures of literacy—which rely onself-reports and other subjective evaluations of liter-acy and education—the 2003 adult literacy assess-ment measured literacy directly by tasks representinga range of literacy activities that adults are likely toface in their daily lives.

The literacy tasks in the assessment were drawn fromactual texts and documents, which were either usedin their original format or reproduced in the assess-ment booklets. Each question appeared before thematerials needed to answer it, thus encouragingrespondents to read with purpose.

Respondents could correctly answer many assess-ment questions by skimming the text or documentfor the information necessary to perform a given lit-eracy task. None of the tasks were multiple choicetasks with a list of responses provided. Instead,respondents had to determine and write theiranswers to the questions.

The 2003 assessment used the same definition of lit-eracy as the 1992 National Adult Literacy Survey:

Using printed and written information to func-tion in society, to achieve one’s goals, and todevelop one’s knowledge and potential.

This definition acknowledges that literacy goesbeyond simply being able to sound out or recognizewords and understand text. A central feature of thedefinition is that literacy is related to achieving anobjective and that adults often read for a purpose.

Measuring Literacy

Three literacy scales—prose literacy, document liter-acy, and quantitative literacy—were used in the 2003assessment:

■ Prose literacy. The knowledge and skills neededto perform prose tasks (i.e., to search, compre-hend, and use information from continuoustexts). Prose examples include editorials, newsstories, brochures, and instructional materials.Prose texts can be further broken down asexpository, narrative, procedural, or persuasive.

■ Document literacy. The knowledge and skillsneeded to perform document tasks (i.e., tosearch, comprehend, and use information fromnoncontinuous texts in various formats).Document examples include job applications,payroll forms, transportation schedules, maps,tables, and drug and food labels.

■ Quantitative literacy. The knowledge and skillsrequired to perform quantitative tasks (i.e., toidentify and perform computations, either aloneor sequentially, using numbers embedded inprinted materials). Examples include balancing acheckbook, figuring out a tip, completing anorder form, and determining the amount ofinterest on a loan from an advertisement.

2


In addition, the assessment included a health literacyscale that consisted of 12 prose, 12 document, and 4quantitative NAAL items.1 The health literacy itemsreflect the definition of health literacy as defined bythe Institute of Medicine and Healthy People 2010(a set of national disease prevention and health pro-motion objectives led by the U.S. Department ofHealth and Human Services):

The degree to which individuals have thecapacity to obtain, process, and understand basichealth information and services needed tomake appropriate health decisions. (HHS 2000and Institute of Medicine 2004)

Tasks used to measure health literacy were organizedaround three domains of health and health careinformation and services: clinical, prevention, and nav-igation of the health care system.The stimulus materialsand the 28 health literacy tasks were designed toelicit respondents’ skills for locating and understand-ing health-related information and services and torepresent the three general literacy scales—prose,document, and quantitative—developed to reportNAAL results.

The materials were selected to be representative ofreal-world health-related information, includinginsurance information, medicine directions, and pre-ventive care information. The Office of DiseasePrevention and Health Promotion (ODPHP) withinthe U.S. Department of Health and Human Servicessuggested materials and questions based on inputfrom other HHS agencies and stakeholders andexperts, and on information from federal healthmaterials and other health-related assessments.

Of the 28 health literacy tasks, 3 represented the clin-ical domain, 14 represented the prevention domain,

and 11 items represented the navigation of the healthcare system domain. The domains are defined in thefollowing way:

■ The clinical domain encompasses those activitiesassociated with the health care provider-patientinteraction, clinical encounters, diagnosis andtreatment of illness, and medication.Tasks fromthe clinical domain are filling out a patientinformation form for an office visit, understand-ing dosing instructions for medication, and fol-lowing a health care provider’s recommendationfor a diagnostic test.

■ The prevention domain encompasses those activ-ities associated with maintaining and improvinghealth, preventing disease, intervening early inemerging health problems, and engaging in self-care and self-management of illness. Examplesare following guidelines for age-appropriatepreventive health services, identifying signs andsymptoms of health problems that should beaddressed with a health professional, and under-standing how eating and exercise habits decreaserisks for developing serious illness.

■ The navigation of the health care system domainencompasses those activities related to under-standing how the health care system works andindividual rights and responsibilities. Examplesare understanding what a health insurance planwill and will not pay for, determining eligibili-ty for public insurance or assistance programs,and being able to give informed consent for ahealth care service. (HHS, 2003, p. 37)

The NAAL health literacy scale did not include tasksthat did not fit the definitions of prose, document, orquantitative literacy even if they were consistent withthe definition of health literacy used by HealthyPeople 2010. For example, none of the NAAL healthtasks required knowledge of specialized health termi-

3

Chapter 1: Introduction

1 The NAAL health literacy scale was constructed to have a meanof 245 and a standard deviation of 55.

nology. The assessment also did not measure the abil-ity to obtain information from nonprint sources,although questions about the use of all sources ofhealth information—both written and oral—wereincluded on the background questionnaire and areincluded in this report.

Background Questionnaire

The 2003 National Assessment of Adult Literacyhousehold background questionnaire was used tocollect data about various demographic and back-ground characteristics of adults. The questionnairealso included a section of questions specifically relat-ed to health status, preventive health practices, healthinsurance coverage, and sources of information abouthealth issues. A summary of the questions that wereused in analyses in this report is presented in appen-dix B on page 27.

A separate background questionnaire was developedfor adults in prison. Questions about health statusand sources of information about health issues wereincluded on the prison background questionnaire.The background questionnaire for prison inmatesdid not include questions about health insurance orabout Internet use.

Interpreting Literacy Results

In addition to reporting average literacy scores, anoth-er way to report results is by grouping adults with sim-ilar scores into a relatively small number of categories,often referred to as performance levels. Performancelevels are used to identify and characterize the relativestrengths and weaknesses of adults falling within vari-ous ranges of literacy ability.Describing the adult pop-ulation according to such levels allows analysts, policy-makers, and others to examine and discuss the typicalperformance and capabilities of specified groups with-in the adult population.2

The National Research Council’s Board on Testingand Assessment (BOTA) Committee on PerformanceLevels for Adult Literacy recommended a new set of performance levels for the prose, document, andquantitative scales for the NAAL, instead of using thesame reporting levels used for the 1992 NationalAdult Literacy Survey.3

Drawing on the committee’s recommendations, theU.S. Department of Education decided to reportNAAL results for the prose, document, and quantita-tive scales by using four literacy levels for each scale:Below Basic, Basic, Intermediate, and Proficient.Table 1-1summarizes the knowledge, skills, and capabilities thatadults needed to demonstrate to be classified into oneof the four levels on the prose, document, and quan-titative scales. The items used for the health literacyscale were also classified as prose, document, andquantitative items.

The BOTA Committee on Performance Levels forAdult Literacy was not asked to recommend per-formance levels for the health scale, because everyhealth literacy task was included on the prose, docu-ment, or quantitative scale. NCES mapped eachhealth task to the health literacy scale based on theirlevel of difficulty as prose, document, and quantita-tive items (see figure 1-1). Each health task wasmapped to the prose, document, or quantitative scale(depending upon which scale the task fell into) at thepoint on the scale (i.e., the scale score) where anadult with that scale score would have a 67 percentprobability of doing the task correctly. The 67 per-cent probability convention was used by the BOTACommittee for the prose, document, and quantitativescales. That point on the scale was classified as towhether it fell into the Below Basic, Basic, Intermediate,or Proficient level.Cut-points for the health scale wereestablished so that each task was classified into the


4

2 For more information on NAAL performance levels see Whiteand Dillow (2005).

3 For a description of the process followed by the BOTACommittee on Performance Levels see Hauser et al. (2005) andWhite and Dillow (2005).


same level on the health scale as on the respectiveprose, document, or quantitative scale.

A health literacy task that was mapped to theProficient level on the prose scale was also mapped tothe Proficient level on the health scale. For example, asshown in figure 1-1, a task that requires a respondentto “evaluate information to determine which legaldocument is applicable to a specific health care situ-ation” maps to 325 on the health scale, which is at

the Proficient level. The same task maps to 361 on theprose scale, which is also at the Proficient level.

Similarly, as shown in figure 1-1, a task that requires arespondent to “determine a healthy weight range for aperson of a specified height, based on a graph thatrelates height and weight to body mass index (BMI)”mapped to 290 on the health scale.This task was alsoincluded on the document scale, where it mapped to320, or the Intermediate level. The cut-points for the

5

Table 1-1. Overview of the literacy levels

Level and definition Key abilities associated with level

Below Basic indicates no more than themost simple and concrete literacy skills.

Score ranges for Below Basic:Prose: 0–209Document: 0–204Quantitative: 0–234

Basic indicates skills necessary to performsimple and everyday literacy activities.

Score ranges for Basic:Prose: 210–264Document: 205–249Quantitative: 235–289

Intermediate indicates skills necessary toperform moderately challenging literacyactivities.

Score ranges for Intermediate:Prose: 265–339Document: 250–334Quantitative: 290–349

Proficient indicates skills necessary to per-form more complex and challenging literacyactivities.

Score ranges for Proficient:Prose: 340–500Document: 335–500Quantitative: 350–500

Adults at the Below Basic level range from being nonliterate in English to havingthe abilities listed below:

■ locating easily identifiable information in short, commonplace prose texts

■ locating easily identifiable information and following written instructions insimple documents (e.g., charts or forms)

■ locating numbers and using them to perform simple quantitative operations(primarily addition) when the mathematical information is very concrete andfamiliar

■ reading and understanding information in short, commonplace prose texts

■ reading and understanding information in simple documents

■ locating easily identifiable quantitative information and using it to solve sim-ple, one-step problems when the arithmetic operation is specified or easilyinferred

■ reading and understanding moderately dense, less commonplace prose textsas well as summarizing, making simple inferences, determining cause andeffect, and recognizing the author’s purpose

■ locating information in dense, complex documents and making simple infer-ences about the information

■ locating less familiar quantitative information and using it to solve problemswhen the arithmetic operation is not specified or easily inferred

■ reading lengthy, complex, abstract prose texts as well as synthesizing infor-mation and making complex inferences

■ integrating, synthesizing, and analyzing multiple pieces of information locatedin complex documents

■ locating more abstract quantitative information and using it to solve multi-step problems when the arithmetic operations are not easily inferred and theproblems are more complex

NOTE: Although the literacy levels share common names with the National Assessment of Educational Progress (NAEP) levels, they do not correspond to the NAEP levels.

SOURCE: Hauser, R.M, Edley, C.F. Jr., Koenig, J.A., and Elliott, S.W. (Eds.). (2005). Measuring Literacy: Performance Levels for Adults, Interim Report.Washington, DC: National Academies Press; White, S. and Dillow, S.

(2005). Key Concepts and Features of the 2003 National Assessment of Adult Literacy (NCES 2006-471). U.S. Department of Education.Washington, DC: National Center for Education Statistics.

6


health scale were set so that the task would also map tothe Intermediate level on the health scale.

As shown in figure 1-1, health tasks that mapped to theBelow Basic level required locating straightforward piecesof information in short simple texts or documents.

Health tasks that mapped to the Basic level generallyrequired finding information in texts and documentsthat were somewhat longer than those in the BelowBasic level, and the information to be found was usual-ly more complex. For example, a task that mapped tothe Basic level required giving two reasons a person with

Figure 1-1. Difficulty of selected health literacy tasks: 2003

Proficient 310–500

Intermediate 226–309

Basic 185–225

Below Basic 0–184

Health literacy scale

0

150

200

100

250

300

400

350

500

253 Determine what time a person can take a prescription medication, based on information on the prescription drug label that relates the timing of medication to eating.

266 Find the age range during which children should receive a particular vaccine, using a chart that shows all the childhood vaccines and the ages children should receive them.

290 Determine a healthy weight range for a person of a specified height, based on a graph that relates height and weight to body mass index (BMI).

382 Calculate an employee’s share of health insurance costs for a year, using a table that shows how the employee’s monthly cost varies depending on income and family size.

366 Find the information required to define a medical term by searching through a complex document.

325 Evaluate information to determine which legal document is applicable to a specific health care situation.

145 Identify what it is permissible to drink before a medical test, based on a set of short instructions.

101 Circle the date of a medical appointment on a hospital appointment slip.

169 Identify how often a person should have a specified medical test, based on information in a clearly written pamphlet.

228 Identify three substances that may interact with an over-the-counter drug to cause a side effect, using information on the over-the-counter drug label.

201 Explain why it is difficult for people to know if they have a specific chronic medical condition, based on information in a one-page article about the medical condition.

202 Give two reasons a person with no symptoms of a specific disease should be tested for the disease, based on information in a clearly written pamphlet.

NOTE:The position of a question on the scale represents the average scale score attained by adults who had a 67 percent probability of successfully answering the question. Only selected questions are presented.

Scale score ranges for performance levels are referenced on the figure.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.

7


no symptoms of a specific disease should be tested forthe disease by using information in a pamphlet, while atask that mapped to the Below Basic level required find-ing one piece of information–the date–on a medicalappointment slip that was shorter and simpler than thetext in the Basic task.

Health tasks that mapped to the Intermediate level wentbeyond simply searching texts and documents to findinformation. Most health tasks that mapped to theIntermediate level required adults to interpret or applyinformation that was presented in complex graphs,tables, or other health-related texts or documents.

Health tasks that mapped to the Proficient level requireddrawing abstract inferences, comparing or contrastingmultiple pieces of information within complex texts ordocuments, or applying abstract or complicated infor-mation from texts or documents.

Conducting the Survey4

The 2003 National Assessment of Adult Literacyincluded two samples: (1) adults ages 16 and older liv-ing in households and (2) prison inmates ages 16 andolder in federal and state prisons.The assessment wasadministered to approximately 19,000 adults: 18,000adults living in households and 1,200 prison inmates.

Each sample was weighted to represent its share of thetotal population of the United States, and the sampleswere combined for reporting. Household data collec-tion was conducted from March 2003 throughFebruary 2004; prison data collection was conductedfrom March through July 2004. For the householdsample, the screener response rate was 81 percent andthe background questionnaire response rate was 77percent.The final household sample response rate was62 percent.4 For the prison sample, 97 percent of pris-

ons that were selected for the study agreed to partic-ipate and the background questionnaire response ratefor prison inmates was 91 percent. The final prisonsample response rate was 88 percent.

Household interviews were conducted in respon-dents’ homes; prison interviews usually took place ina classroom or library in the prison.Whenever possi-ble, interviewers administered the background ques-tionnaire and assessment in a private setting.Assessments were administered one-on-one using acomputer-assisted personal interviewing (CAPI) system programmed into laptop computers.Respondents were encouraged to use whatever aidsthey normally used when reading and when per-forming quantitative tasks, including eyeglasses, mag-nifying glasses, rulers, and calculators.

Three percent of adults were unable to participate inthe assessment because they could not communicatein either English or Spanish or because they had amental disability that prevented them from beingtested. Literacy scores for these adults could not beestimated, and they are not included in the resultspresented in this report, or in other NAAL reports.

An additional 3 percent of adults were routed to an alternative assessment (the Adult LiteracySupplemental Assessment, or ALSA) based upon theirperformance on the seven easy screening tasks at thebeginning of the literacy assessment. Because theycould be placed on the NAAL scale based on theirresponses to the seven screening tasks,ALSA partici-pants were classified into the Below Basic level oneach NAAL literacy scale. Results for the adults whowere placed in the ALSA are included in the resultspresented in this report.

Additional information on ALSA, sampling,response rates, and data collection procedures is inappendix C.

4 Nonresponse bias analyses are discussed on page 34 of the report.All percentages in this section are weighted. For the unweightedpercentages, see tables C-1 and C-2 in appendix C.

Interpretation of Results

The statistics presented in this report are estimates ofperformance based on a sample of respondents,rather than the values that could be calculated ifevery person in the nation answered every questionon the assessment. Estimates of performance of thepopulation and groups within the population werecalculated by using sampling weights to account forthe fact that the probabilities of selection were notidentical for all respondents. Information about theuncertainty of each statistic that takes into accountthe complex sample design was estimated by usingTaylor series procedures to estimate standard errors.

The analyses in this report examine differences relatedto literacy based on self-reported background charac-teristics among groups in 2003, by using standard ttests to determine statistical significance. Statistical sig-nificance is reported at p < .05. Differences betweenaverages or percentages that are statistically significantare discussed by using comparative terms such ashigher or lower. Differences that are not statisticallysignificant either are not discussed or are referred toas “not statistically significant.” Failure to find a sta-tistically significant difference should not be inter-preted as meaning that the estimates are the same;rather, failure to find a difference may also be due tomeasurement error or sampling.

Detailed tables with estimates and standard errors forall tables and figures in this report are in appendices

D and E. Appendix C includes more informationabout the weights used for the sample and the pro-cedures used to estimate standard errors and statisti-cal significance.

Cautions in Interpretation

The purpose of this report is to examine the rela-tionship between health literacy and various self-reported background factors. This report is purelydescriptive in nature. Readers are cautioned not todraw causal inferences based solely on the results pre-sented here. It is important to note that many of thevariables examined in this report are related to oneanother, and complex interactions and relationshipshave not been explored here.

Organization of the Report

Chapter 2 of this report examines how health litera-cy varied across groups with different demographiccharacteristics, as well as the relationship betweenhealth literacy and highest level of educational attain-ment and poverty status.

Chapter 3 explores the relationship between literacyand overall health. The analyses in the chapter alsoexamine the literacy of adults who have differenttypes of health insurance or no health insurance.Thechapter concludes with an examination of the rela-tionship between literacy and sources of printed andnonprinted information used by adults.

8


Demographic Characteristics andHealth Literacy

Data from the 2003 National Assessment ofAdult Literacy (NAAL) allow examina-tions of the relationships between demo-

graphic characteristics and literacy. Analyses fromthe assessment showed differences in prose, docu-ment, and quantitative literacy for adults with dif-ferent demographic characteristics. For example,women had higher prose and document literacythan men, while women’s average quantitative liter-acy was lower than men’s.The average prose, docu-ment, and quantitative literacy of White adults washigher than the average literacy of adults of otherraces or ethnicities.Adults 65 years of age and olderhad the lowest average prose, document, and quan-titative scores among all age groups (Kutner et al.2005).

The relationships between health literacy anddemographic characteristics of adults are examinedin this chapter.Also examined are the relationshipsbetween health literacy and highest level of educa-tional attainment and poverty. All the analyses inthis chapter are based on the combined householdand prison samples.

9

Total Population

Gender

Race and Ethnicity

Language Spoken Before

Starting School

Age

Highest Level of Educational

Attainment

Poverty Threshold

Summary

2CHAPTER TWO

10


Total Population

The majority of adults, 53 percent, had Intermediatehealth literacy (figure 2-1).An additional 22 percentof adults had Basic health literacy, 14 percent hadBelow Basic health literacy, and 12 percent hadProficient health literacy. The distribution of adultsamong the different health literacy levels is similar,although not identical, to the distribution of adultsamong the levels of the prose, document, and quan-titative scales (Kutner et al. 2005).

Gender

The average health literacy score for women was248, which is 6 points higher than the average healthliteracy score for men (figure 2-2).A higher percent-age of men than women had Below Basic health liter-acy, by a margin of 4 percentage points.The percent-age of women with Intermediate health literacy was 4 percentage points higher than the percentage ofmen at the same level (figure 2-3). There were nosignificant differences in the percentages of men andwomen with Basic or Proficient health literacy.

Figure 2-3. Percentage of adults in each health

literacy level, by gender: 2003

Below Basic Basic Intermediate Proficient

16 22 51 11

12 21 55 12

0 20 40 60 80 1006080 40 20Percent Below Basic Percent Basic and above

Gender

Women

Men

NOTE: Detail may not sum to totals because of rounding. Adults are defined as people 16 years of

age and older living in households or prisons. Adults who could not be interviewed because of lan-

guage spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for

Education Statistics, 2003 National Assessment of Adult Literacy.


literacy level: 2003



All adults 14 22 53 12






Figure 2-2. Average health literacy scores of adults,

by gender: 2003

Men Women

242 248

0

150

200

250

Average score

300

350

500

Gender

NOTE: Adults are defined as people 16 years of age and older living in households or prisons. Adults

who could not be interviewed because of language spoken or cognitive or mental disabilities (3

percent in 2003) are excluded from this figure.



11

Chapter 2: Demographic Characteristics and Health Literacy

Race and Ethnicity

The average health literacy scores for differentracial/ethnic groups are shown in figure 2-4.Whiteand Asian/Pacific Islander adults had higher averagehealth literacy than Black, Hispanic, AmericanIndian/Alaska Native, and Multiracial adults.Hispanic adults had lower average health literacythan adults in any of the other racial/ethnic groups.There was no significant difference in average healthliteracy between White and Asian/Pacific Islanderadults. There was also no significant difference inaverage health literacy between Black and AmericanIndian/Alaska Native adults.

The percentages of White and Asian/Pacific Islanderadults with Proficient health literacy were higher than

the percentages of Black, Hispanic, AmericanIndian/Alaska Native, or Multiracial adults withProficient health literacy (figure 2-5).

Fifty-eight percent of White, 52 percent ofAsian/Pacific Islander, and 59 percent of Multiracialadults had Intermediate health literacy, compared with41 percent of Black adults and 31 percent of Hispanicadults. Conversely, higher percentages of Black andHispanic adults than White,Asian/Pacific Islander, orMultiracial adults had Below Basic health literacy.

The percentages of Black, Hispanic, and Multiracialadults with Basic health literacy were higher than thepercentages of White or Asian/Pacific Islander adultswith Basic health literacy.


by race/ethnicity: 2003

0

150

200

250

Average score

300

350

500

Race/ethnicity

White Black Hispanic Asian/Pacific

Islander

American Indian/

Alaska Native

Multiracial

256

216

197

255

227238



percent in 2003) are excluded from this figure. All adults of Hispanic origin are classified as

Hispanic, regardless of race.The Asian/Pacific Islander category includes Native Hawaiians. Black

includes African American, and Hispanic includes Latino.




literacy level, by race/ethnicity: 2003



Race/ethnicity

Multiracial

American Indian/Alaska Native

Asian/Pacific Islander

Hispanic

Black

White 9

24 34 41 2

41 25 31 4

13

25

9 28 59 3

19 58 14

18 52 18

23 45 7




All adults of Hispanic origin are classified as Hispanic, regardless of race.The Asian/Pacific Islander

category includes Native Hawaiians. Black includes African American, and Hispanic includes Latino.




Language Spoken Before Starting School

Adults who spoke only English before starting schoolhad higher average health literacy than adults whospoke only a language other than English beforestarting school (table 2-1).The average health litera-cy score of adults who spoke only English beforestarting school was at the Intermediate level, as werethe average health literacy scores of adults who spokeEnglish and Spanish or English and another lan-guage.Adults who spoke only Spanish before startingschool had the lowest average health literacy, equiva-lent to Below Basic health literacy.

Age

Adults in the oldest age group—65 and older—hadlower average health literacy than adults in younger agegroups (figure 2-6). Adults ages 25 to 39 had higheraverage health literacy than adults in other age groups.

The percentages of adults with Intermediate health lit-eracy in all age groups, except 65 and older, rangedfrom 53 to 58 percent. Among adults ages 65 andolder, 38 percent had Intermediate health literacy. Ahigher percentage of adults ages 65 or older had BelowBasic or Basic health literacy than adults in any of theyounger age groups (figure 2-7). Moreover, the per-centages of adults in the 65 and older age group who


by age: 2003

0

150

200

250

Average score

300

350

500

Age

16–18 19–24 25–39 40–49 50–64 65+

244 249256

249 246

214







literacy level, by age: 2003



Age

65+

50–64

40–49

25–39

19–24

16–18 11

10

10

11

13

29 30 38 3

23 58 8

21 58 11

18 55 16

21 56 12

21 53 12






Table 2-1. Average health literacy scores of adults,

by language spoken before starting

school: 2003

Language spoken before starting school Average

English only 251

English and Spanish 232

English and other 244

Spanish 174

Other language 229

NOTE:Adults are defined as people 16 years of age and older living in households or prisons. Adults


percent in 2003) are excluded from this table.The English and Spanish category includes adults

who spoke languages in addition to both English and Spanish.The Spanish category includes

adults who spoke Spanish and additional non-English languages.



12

Figure 2-8. Average health literacy scores of adults, by highest educational attainment: 2003

241

184

232 232241

253264

280287

0

150

200

250

Average score

300

350

500

Educational attainment

Still in high school Less than high school/some high school

GED/high school equivalency

High school graduate

Vocational/trade/business school

Some college Bachelor’s degree Graduate studies/degree

Associate’s/2-year degree

NOTE: Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003)

are excluded from this figure.


had Intermediate or Proficient health literacy were lowerthan the percentages of adults in the other age groupswho had health literacy in those levels.A higher per-centage of 25- to 39-year-old adults than adults in anyof the other age groups had Proficient health literacy.

The youngest adults, adults ages 16 to 18, were lesslikely to have Proficient health literacy than adults ages25 to 39 or adults ages 50 to 64.

Highest Level of Educational Attainment

Starting with adults who had graduated from highschool or obtained a GED, average health literacyincreased with each higher level of educationalattainment (figure 2-8). Adults who had not attend-ed or completed high school, and were not current-ly enrolled in school, had lower average health liter-acy than adults with higher levels of education oradults who were currently enrolled in high school.

A higher percentage of adults who had not attended orcompleted high school had Below Basic health literacythan adults in any other educational group (figure 2-9).

These same adults—adults who had not attended orcompleted high school and were not currently enrolledin school—were less likely than all other adults, exceptfor those who had a GED or high school equivalencycertificate, to have Proficient health literacy.

Higher percentages of adults who had taken somegraduate classes or completed a graduate degree, andadults who had graduated from a 4-year college, hadProficient health literacy than adults with lower levels ofeducation. However, there were no significant differ-ences between the two highest educational groups(adults with a bachelor’s degree and adults with gradu-ate studies or a graduate degree) in the percentages ofadults falling in each of the four health literacy tasks.

Four percent of adults with an associate’s or 2-yeardegree and 3 percent of adults with a 4-year collegedegree or graduate studies had Below Basic health lit-eracy, while 12 to 15 percent of adults who were stillin high school, had obtained a high school diploma,had obtained a GED certificate, or had taken somevocational, trade, or business classes after high schoolhad Below Basic health literacy.

13

Chapter 2: Demographic Characteristics and Health Literacy

14


Poverty Threshold

Adults living below the poverty level had an averagehealth literacy score of 205, while adults living at thepoverty level or up to 125 percent of the povertylevel had an average health literacy score of 222(table 2-2). Both of these average literacy scores arein the Basic health literacy level.Average health liter-acy was highest for adults who were above 175 per-cent of the poverty threshold; in this group, averagehealth literacy was in the Intermediate range.5

Summary

The majority of adults, 53 percent, had Intermediatehealth literacy.An additional 22 percent of adults hadBasic health literacy. Fewer than 15 percent of adultshad either Below Basic or Proficient health literacy.Starting with adults who had graduated from highschool, or obtained a GED or high school equivalen-cy certificate, average health literacy increased witheach higher level of education.Adults living below thepoverty level had lower average health literacy thanadults living above the poverty threshold.

Women had higher average health literacy than men.White and Asian/Pacific Islander adults had higheraverage health literacy than Black, Hispanic,AmericanIndian/Alaska Native, and Multiracial adults. Hispanicadults had lower average health literacy than adults inany of the other racial/ethnic groups. Adults whospoke only English before starting school had a high-er average health literacy than adults who spoke onlySpanish or another non-English language.Adults ages65 and older had lower average health literacy thanadults in younger age groups.More adults ages 65 andolder also had Below Basic health literacy than adultsin any of the younger age groups.


literacy level, by highest educational

attainment: 2003


Graduate studies/degree

Bachelor’s degree

Some college

Vocational/trade/business school

High school graduate

GED/high school equivalency

Less than/some high school

Still in high school 13

49 27 23 1

14 30 54 3

15 29 53 4

12

5

4

3

3

Associate’s/2-year degree

24 56 7

25 57 7

20 67 8

15 66 15

10 60 27

8 57 33


Educational attainment






5 Analysis of average health literacy by occupation is presented inappendix E.

Table 2-2. Average health literacy scores of adults,

by poverty threshold: 2003

Poverty threshold Average

Below poverty threshold 205

100–125% of poverty threshold 222



Above 175% of poverty threshold 261



percent in 2003) are excluded from this table. Poverty thresholds are determined by the U.S.

Census Bureau and are based on family income, family size, and the ages of family members.

Because adults provided their income in ranges rather than by precise dollar figures, adults could

not be exactly matched to a federal poverty category.The categories shown in this table represent

the best matches possible based on the categorical data.



Overall Health, Health InsuranceCoverage, and Sources of InformationAbout Health Issues

Health literacy is of interest to providers ofhealth outreach programs for different seg-ments of the population. These providers

may include health insurance companies and peoplewho are designing educational programs related tohealth maintenance and improvement. A review ofmedical and public health literature noted that liter-acy has a direct influence on patient “access to cru-cial information about their rights and their healthcare, whether it involves following instruction forcare, taking medicine, comprehending disease-relat-ed information, or learning about disease preven-tion and health promotion” (Rudd et al. 1999).

This chapter examines the health literacy levels ofdifferent populations who may be targeted byhealth outreach programs, including adults with dif-ferent levels of overall health and adults who havedifferent types of health insurance coverage or nohealth insurance coverage at all.The analyses in thechapter also explore where adults with different lev-els of health literacy get information about healthissues.

The analyses of the literacy of adults who receivedvarious types of health insurance are based on thehousehold sample only. Analyses of adults whoreceived information about health issues from theInternet are also based on the household sample only

15

Self-Assessment of Overall

Health

Health Insurance

Sources of Information About

Health Issues

Summary

3CHAPTER THREE


because prison inmates generally do not have access tothe Internet.All other analyses in this chapter are basedon the combined household and prison samples.

This chapter focuses on the relationship betweenhealth literacy and self-reported overall health, healthinsurance coverage, and sources of information abouthealth issues. As shown in chapter 2, health literacyvaries across demographic groups (i.e., by sex,race/ethnicity, age, and education). Overall health,health insurance coverage, and sources of informationabout health issues are also likely to vary across thesesame demographic groups. Because of that, supple-mental analyses showing the relationships betweenhealth literacy and self-reported overall health, healthinsurance coverage, and sources of information abouthealth issues broken out by demographic groups areprovided in appendix E.

Self-Assessment of Overall Health

Figure 3-1 summarizes the average health literacyscores for adults with different levels of self-report-ed overall health.At each higher level of self-report-ed level of overall health, adults had higher averagehealth literacy than adults in the next lower level.The average health literacy score of adults whoreported excellent health was 262. Adults whoreported they had very good health had averagehealth literacy scores of 254; adults with self-report-ed good health had average health literacy scores of234; adults with self-reported fair health had averagehealth literacy scores of 207; and adults with self-reported poor health had average health literacyscores of 196 (figure 3-1).

Smaller percentages of adults who reported theirhealth was excellent or very good than adults whoreported their health was poor, fair, or good had BelowBasic health literacy (figure 3-2). Conversely, higherpercentages of adults who reported their overall health


by self-assessment of overall health:

2003

196207

234

254262

0

150

200

250

Average score

300

350

500

Overall health

Poor Fair Good Very good Excellent






16


literacy level, by self-assessment of

overall health: 2003


42 27 29 3

33 30 34 3

16

9

8Excellent

Very good

Good

Fair

Poor

19 59 13

17 57 19

27 51 6


Overall health






was very good or excellent had Intermediate orProficient health literacy than adults who said theiroverall health was poor, fair, or good.

Most differences within health literacy levels in fig-ure 3-2 are significant. However, significant differ-ences were not detected between the percentages ofadults with self-reported excellent health and verygood health with Below Basic and Intermediate healthliteracy, between the percentages of adults with self-reported good health and poor health with Basichealth literacy, and between the percentages of adultswith self-reported fair health and poor health withProficient health literacy.

Health Insurance

Adults in the United States may receive healthinsurance through a variety of public and privatesources. These include group insurance that is pro-vided through an employer of the individual or afamily member, military insurance for active orretired service members and their families, privatelypurchased individual insurance policies, or insurancethrough a government program. The two majorgovernment programs that provide health insuranceare Medicare and Medicaid. Medicare provides cov-erage for most adults ages 65 and older in theUnited States, in addition to some younger adultswith disabilities. Medicaid coverage is limited tolow-income adults who also meet other criteria thatvary by state.

Adults who received health insurance through anemployer had higher average health literacy thanadults who received health insurance through othersources or adults who had no health insurance (fig-ure 3-3).Adults who received Medicare or Medicaidand adults who had no health insurance coverage hadlower average health literacy than adults who werecovered by other types of health insurance.

Among adults who received Medicare or Medicaid,27 percent and 30 percent, respectively, had BelowBasic health literacy (figure 3-4). Twenty-eight per-cent of adults who had no health insurance hadBelow Basic health literacy. Among adults whoreceived employer-provided, military, or privatelypurchased health insurance, the percentages withBelow Basic health literacy were lower, 7 percent, 12percent, and 13 percent, respectively.

Among adults who received employer-providedhealth insurance, 62 percent had Intermediate healthliteracy and 14 percent had Proficient health literacy(figure 3-4).The percentages of adults who receivedMedicare or Medicaid and had Intermediate orProficient health literacy were lower than those whoreceived other types of health insurance.


by type of health insurance coverage:

2003

Employer provided

Military Privately purchased

Medicare Medicaid No insurance

259248 243

216 212220

0

150

200

250

Average score

300

350

500

Type of health insurance

NOTE: Adults are defined as people 16 years of age and older living in households. Adults who could

not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in

2003) are excluded from this figure. Adults who reported they had more than one type of health

insurance are included in each applicable category in this figure.



Chapter 3: Overall Health, Health Insurance Coverage, and Sources of Information About Health Issues

17

Sources of Information About Health Issues

Adults may get health information in a variety ofways, including through traditional (newspapers,magazines, and books or brochures) and nontradi-tional (the Internet) forms of print media andthrough nonprint media (radio and television).Adults may also get information about health issuesfrom conversations with family, friends, or coworkersor conversations with health care professionals.

Printed and Written Media

Many adults receive information about health issuesfrom such traditional printed sources as newspapers,magazines, and books or brochures. America’s adults

also have access to a huge amount of written healthinformation on the Internet.A recent Harris Poll esti-mates that roughly 100 million adults go online tofind health information (Taylor 2001).Another studyfound that 70 percent of consumers reported havingmade a health care decision on the basis of informa-tion they found online (Fox and Rainie 2000).

Lower percentages of adults with Below Basic healthliteracy than adults with Basic, Intermediate, orProficient health literacy reported that they got infor-mation about health issues from any written sources,including newspapers, magazines, books orbrochures, and the Internet (figure 3-5).Twenty per-cent of adults with Below Basic health literacy gotinformation about health issues from the Internet,compared with 42 percent of adults with Basic healthliteracy, 67 percent of adults with Intermediate healthliteracy, and 85 percent of adults with Proficient healthliteracy. Lower percentages of adults with Below Basic,Basic, or Intermediate health literacy got informationabout health issues from the Internet than from otherwritten sources (figure 3-5).

A higher percentage of adults with Proficient healthliteracy than adults with lower levels of health litera-cy got a lot of information about health issues fromthe Internet. Higher percentages of adults with Basicor Intermediate health literacy than adults with eitherlower (Below Basic) or higher (Proficient) health liter-acy got a lot of information about health issues fromnewspapers and magazines. Higher percentages ofadults with Basic, Intermediate, or Proficient health lit-eracy than adults with Below Basic health literacy gota lot of information about health issues from booksor brochures.

Higher percentages of adults with Proficient healthliteracy got information about health issues frombooks or brochures than from newspapers or theInternet. Additionally, higher percentages of adults


18


literacy level, by type of health

insurance coverage: 2003



Type of health insurance

7

12

13

27

30

28No insurance

Medicaid

Medicare

Privately purchased

Military

Employer provided 17 62 14

21 56 11

24 54 9

30 40 3

30 38 3

25 41 7


age and older living in households. Adults who could not be interviewed because of language spo-

ken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure. Adults who

reported they had more than one type of health insurance are included in each applicable category

in this figure.



19


Figure 3-5. Percentage of adults who got information about health issues from printed and written media:

newspapers, magazines, books or brochures, and the Internet, by health literacy level: 2003

4122 14 12

Newspapers Magazines

NoneA littleSomeA lot

Books or brochures Internet

Percent got no information

Percent got information

0

20

20

40

40

60

60

80

80

100

100Below Basic Basic Intermediate Proficient

Literacy level



0

20

20

40

40

60

60

80

80

100


Literacy level



0

20

20

40

40

60

60

80

80

100


Literacy level



0

20

20

40

40

60

60

80

80

100


Literacy level

3724 19 20

4120 13 11

8058

3315

29

22

12

35

27

15

36

31

14

32

38

10

27

23

1037

25

17

41

28

18

40

35

12

7 57

16

12

14 27

19

21

37

22

26

28

21

1139

25

16

41

28

18

36

35

18

NOTE: Detail may not sum to totals because of rounding. Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or

cognitive or mental disabilities (3 percent in 2003) are excluded from this figure. Prison inmates are not included in the Internet category because they do not have access to the Internet.


with Proficient health literacy got informationabout health issues from the Internet than fromnewspapers.

Nonprint Media

Higher percentages of adults with Below Basic orBasic health literacy than adults with Intermediatehealth literacy received a lot of information abouthealth issues from radio and television. Adults withProficient health literacy were least likely to receive alot of information about health issues from thosesame nonprint media sources (figure 3-6).

Personal Contacts

With each higher level of health literacy, a higherpercentage of adults got information about healthissues from family members, friends, or coworkers(or, in the case of prison inmates, from family mem-bers, friends, other inmates, or staff) (figure 3-7).

Higher percentages of adults with Intermediate orProficient health literacy than adults with Basic healthliteracy got any information about health issues fromhealth care professionals, including doctors, nurses,therapists, and psychologists. A higher percentage ofadults with Basic health literacy than adults withBelow Basic health literacy got any information aboutthese issues from health care professionals.

Summary

At every higher self-reported level of overall health(poor, fair, good, very good, excellent), adults hadhigher average health literacy than adults in the nextlower level. Smaller percentages of adults who report-ed that their overall health was very good or excellenthad Below Basic health literacy than other adults.

Adults who received Medicare or Medicaid or whohad no health insurance had lower average health lit-eracy than adults who received insurance through anemployer or the military or adults who purchasedprivate insurance. Among adults who receivedMedicare and Medicaid, 27 percent and 30 percent,respectively, had Below Basic health literacy.

A lower percentage of adults with Below Basic healthliteracy than adults with Basic, Intermediate, or Proficienthealth literacy reported that they got informationabout health issues from any written sources, includ-ing newspapers, magazines, books or brochures, and

20


Figure 3-6. Percentage of adults who got information

about health issues from nonprint media:

radio and television, by health literacy

level: 2003

None A little Some A lot



0

20

20

40

40

60

60

80

80

100


Literacy level

33

34

19

14

25

44

24

7

17

43

30

98

31

40

21






the Internet. A higher percentage of adults withProficient health literacy than adults with lower levelsof health literacy got a lot of information abouthealth issues from the Internet.A lower percentage ofadults with Below Basic, Basic, and Intermediate healthliteracy got information about health issues from theInternet than from other written sources.

A lower percentage of adults with Proficient health lit-eracy than adults with Intermediate health literacy

received a lot of information about health issues fromradio or television, and a lower percentage of adultswith Intermediate health literacy than adults with Basicor Below Basic health literacy received a lot of infor-mation about health issues from radio or television.

With each higher level of health literacy, the percent-age of adults who got information about health issuesfrom personal contacts other than health care profes-sionals was higher.


21

Figure 3-7. Percentage of adults who got information about health issues from personal contacts: family,

friends, or coworkers; or health care professionals, by health literacy level: 2003

18 11 8 824 15 9

Family, friends, or coworkers (household only),

other inmates (prison only), or staff (prison only) Health care professionals

None A little Some A lot

36

29

17

37

33

19

34

37

21

30

39

23

19

35

23

20

40

25

19

44

28

17

48

31

5



0

20

20

40

40

60

60

80

80

100


Literacy level



0

20

20

40

40

60

60

80

80

100


Literacy level

NOTE: Detail may not sum to totals because of rounding. Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or

cognitive or mental disabilities (3 percent in 2003) are excluded from this figure. Adults living in households were asked about getting information from “family members, friends, or coworkers”; prison inmates

were asked about getting information from “family members, friends, other inmates, or staff.”


the health literacy of america’s adults · the health literacy scale and health literacy tasks...

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