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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.
NCES activities are designed to address high-priority education data needs; provide consistent, reliable, complete, and accu-rate indicators of education status and trends; and report timely, useful, and high-quality data to the U.S. Department ofEducation, the Congress, the states, other education policymakers, practitioners, data users, and the general public. Unlessspecifically noted, all information contained herein is in the public domain.
We strive to make our products available in a variety of formats and in language that is appropriate to a variety of audiences.You, as our customer, are the best judge of our success in communicating information effectively. If you have any commentsor suggestions about this or any other NCES product or report, we would like to hear from you. Please direct your commentsto
National Center for Education StatisticsInstitute of Education SciencesU.S. Department of Education1990 K Street NWWashington, DC 20006–5651
September 2006
The NCES World Wide Web Home Page address is http://nces.ed.gov.The NCES World Wide Web Electronic Catalog is http://nces.ed.gov/pubsearch.
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
U.S. Department of EducationED PubsP.O. Box 1398Jessup, MD 20794–1398
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
The Health Literacy of America’s Adults
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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The Health Literacy of America’s Adults
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
D3-6. Estimates and standard errors for Figure 3-6. Percentage of adults who got information about health issues from
nonprint media: radio and television, by health literacy level: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
D3-7. Estimates and standard errors for 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 . . . . . . . . . . . . . .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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The Health Literacy of America’s Adults
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
E-12. Average health literacy scores of adults who got information about health issues from newspapers, magazines,
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
E-14. Average health literacy scores of adults who got information about health issues from newspapers, magazines,
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
E-16. Average health literacy scores of adults who got information about health issues from newspapers, magazines,
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
E-19. Average health literacy scores of adults who got information about health issues from radio and television,
by race/ethnicity: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
E-20. Average health literacy scores of adults who got information about health issues from radio and television,
by age: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
E-21. Average health literacy scores of adults who got information about health issues from radio and television,
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
E-24. Average health literacy scores of adults who got information about health issues from family, friends, or coworkers,
by race/ethnicity: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
E-25. Average health literacy scores of adults who got information about health issues from health care professionals,
by race/ethnicity: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
E-26. Average health literacy scores of adults who got information about health issues from family, friends, or coworkers,
by age: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
E-27. Average health literacy scores of adults who got information about health issues from health care professionals,
by age: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
E-28. Average health literacy scores of adults who got information about health issues from family, friends, or coworkers,
by highest educational attainment: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
E-29. Average health literacy scores of adults who got information about health issues from health care professionals,
by highest educational attainment: 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
The Health Literacy of America’s Adults
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
The Health Literacy of America’s Adults
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
The Health Literacy of America’s Adults
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).
Chapter 1: Introduction
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
The Health Literacy of America’s Adults
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
Chapter 1: Introduction
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
The Health Literacy of America’s Adults
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
The Health Literacy of America’s Adults
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.
Figure 2-1. Percentage of adults in each health
literacy level: 2003
Below Basic Basic Intermediate Proficient
0 20 40 60 80 1006080 40 20Percent Below Basic Percent Basic and above
All adults 14 22 53 12
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.
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.
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for
Education Statistics, 2003 National Assessment of Adult Literacy.
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.
Figure 2-4. Average health literacy scores of adults,
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
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. 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.
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for
Education Statistics, 2003 National Assessment of Adult Literacy.
Figure 2-5. Percentage of adults in each health
literacy level, by race/ethnicity: 2003
Below Basic Basic Intermediate Proficient
0 20 40 60 80 1006080 40 20Percent Below Basic Percent Basic and above
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
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.
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.
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for
Education Statistics, 2003 National Assessment of Adult Literacy.
The Health Literacy of America’s Adults
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
Figure 2-6. Average health literacy scores of adults,
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
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.
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for
Education Statistics, 2003 National Assessment of Adult Literacy.
Figure 2-7. Percentage of adults in each health
literacy level, by age: 2003
Below Basic Basic Intermediate Proficient
0 20 40 60 80 1006080 40 20Percent Below Basic Percent Basic and above
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
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.
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
who could not be interviewed because of language spoken or cognitive or mental disabilities (3
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.
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for
Education Statistics, 2003 National Assessment of Adult Literacy.
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.
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
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
The Health Literacy of America’s Adults
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.
Figure 2-9. Percentage of adults in each health
literacy level, by highest educational
attainment: 2003
Below Basic Basic Intermediate Proficient
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
0 20 40 60 80 1006080 40 20Percent Below Basic Percent Basic and above
Educational attainment
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.
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
126–150% of poverty threshold 224
151–175% of poverty threshold 231
Above 175% of poverty threshold 261
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 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.
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for
Education Statistics, 2003 National Assessment of Adult Literacy.
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
The Health Literacy of America’s Adults
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
Figure 3-1. Average health literacy scores of adults,
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
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.
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for
Education Statistics, 2003 National Assessment of Adult Literacy.
16
Figure 3-2. Percentage of adults in each health
literacy level, by self-assessment of
overall health: 2003
Below Basic Basic Intermediate Proficient
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
0 20 40 60 80 1006080 40 20Percent Below Basic Percent Basic and above
Overall health
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.
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.
Figure 3-3. Average health literacy scores of adults,
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.
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for
Education Statistics, 2003 National Assessment of Adult Literacy.
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
The Health Literacy of America’s Adults
18
Figure 3-4. Percentage of adults in each health
literacy level, by type of health
insurance coverage: 2003
Below Basic Basic Intermediate Proficient
0 20 40 60 80 1006080 40 20Percent Below Basic Percent Basic and above
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
NOTE: Detail may not sum to totals because of rounding. Adults are defined as people 16 years of
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.
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for
Education Statistics, 2003 National Assessment of Adult Literacy.
19
Chapter 3: Overall Health, Health Insurance Coverage, and Sources of Information About Health Issues
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
Percent got no information
Percent got information
0
20
20
40
40
60
60
80
80
100
100Below Basic Basic Intermediate Proficient
Literacy level
Percent got no information
Percent got information
0
20
20
40
40
60
60
80
80
100
100Below Basic Basic Intermediate Proficient
Literacy level
Percent got no information
Percent got information
0
20
20
40
40
60
60
80
80
100
100Below Basic Basic Intermediate Proficient
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.
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
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
The Health Literacy of America’s Adults
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
Percent got no information
Percent got information
0
20
20
40
40
60
60
80
80
100
100Below Basic Basic Intermediate Proficient
Literacy level
33
34
19
14
25
44
24
7
17
43
30
98
31
40
21
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.
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.
Chapter 3: Overall Health, Health Insurance Coverage, and Sources of Information About Health Issues
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
Percent got no information
Percent got information
0
20
20
40
40
60
60
80
80
100
100Below Basic Basic Intermediate Proficient
Literacy level
Percent got no information
Percent got information
0
20
20
40
40
60
60
80
80
100
100Below Basic Basic Intermediate Proficient
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.”
SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.