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Health Literacy Skills of U.S. Adults

  • Harvard T.H. Chan School of Public Health

Abstract and Figures

To examine adults' literacy proficiencies in multiple health contexts. One hundred ninety-one (191) health-related items drawn from all large-scale adult literacy surveys before 2003 were scored as an independent health literacy scale. Latent class analyses provide portraits of adults with different health literacy skills. Adults without a high school diploma or GED, with health-related restrictions, with limited access to resources, who are members of minority population groups, and who are immigrants - have lower health literacy skills than do others. The distribution of health literacy is not independent of general literacy skills at population or subpopulation levels.
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Health Literacy Skills of U.S. Adults
Rima E. Rudd, MSPH, ScD
Rima E. Rudd, Senior Lecturer on Society,
Human Development, and Health, Department of
Society, Human Development and Health, Harvard
School of Public Health, Boston MA.
Address correspondence to Dr Rudd, Depart-
ment of Society, Human Development and Health,
Harvard School of Public Health, 677 Huntington
Avenue, Boston MA 02115. E-mail:
Objectives: To examine adults’
literacy proficiencies in multiple
health contexts. Methods: One
hundred ninety-one (191) health-
related items drawn from all large-
scale adult literacy surveys be-
fore 2003 were scored as an inde-
pendent health literacy scale. La-
tent class analyses provide por-
traits of adults with different
health literacy skills. Results:
Adults without a high school di-
ploma or GED, with health-related
restrictions, with limited access
to resources, who are members of
minority population groups, and
who are immigrants – have lower
health literacy skills than do oth-
ers. Conclusions: The distribu-
tion of health literacy is not inde-
pendent of general literacy skills
at population or subpopulation lev-
Key word: health literacy
Am J Health Behav. 2007;31(Suppl
n 1993 and again in 2005, the portraits
of adult literacy proficiencies that
emerged from the National Center for
Education Statistics were met with shock
and dismay. These surveys indicate that
approximately half of US adults lack the
literacy skills needed for full participa-
tion in the current economy and for the
demands of everyday life in an industrial-
ized nation. Although both reports note
that illiteracy is rare in the United States,
findings indicate that large numbers of
adults in the United States have difficulty
using, with accuracy and consistency,
the many complex print materials found
in everyday life and needed for routine
tasks. Well over 800 studies published
over the past 2 and a half decades indicate
that many health materials are written
at reading grade levels that exceed the
reading skills of an average high school
graduate. In addition, close to 100 studies
show a relationship between reading
skills of adults and a variety of health
activities and health outcomes.
Recent seminal reports from the US
Department of Health and Human Ser-
the Agency for Healthcare Re-
search and Quality,
and the Institute of
(IOM) have provided reviews
and commentary on issues and study
findings in the emerging area of inquiry
that has come to be known as health
literacy. The IOM report, offering the most
detailed analysis of health literacy in the
United States to date, called for the devel-
opment of new measures of health lit-
eracy that went beyond approximations of
reading skills to more accurately reflect a
full array of literacy skills – reading, writ-
ing, oral presentation, aural comprehen-
sion, and basic mathematical computa-
The primary objective of the study de-
scribed herein was to provide an analysis
of health literacy skills among US adults
based on an understanding of literacy as
a set of functional skills, measured by
one’s ability to use print materials to
accomplish everyday health tasks. In or-
der to conduct such an analysis, a derived
assessment of health literacy was con-
ducted based on the most prominent na-
Am J Health Behav.
2007;31(Suppl 1):S8-S18
tional and international surveys of adult
literacy proficiencies. The study began
with the development of a health activi-
ties framework based on a range of health
contexts, including but not limited to
health care settings. A secondary objec-
tive was to offer baseline data of US adult
health literacy proficiencies in multiple
health contexts. Study findings offer a
comprehensive portrait of health literacy
among US adults. Overall, the study pro-
cess and, particularly, the analysis of
health tasks offer insight for the develop-
ment of intervention studies.
The study is based on a health activi-
ties typology that includes health promo-
tion, health protection, disease preven-
tion, health care and disease manage-
ment, and systems navigation. Research-
ers, versed in the typology of health ac-
tivities, examined and analyzed all items
on all large-scale adult literacy surveys
conducted before 2003. These surveys
included the 1986 assessment of the
nation’s young population,
the 1990 as-
sessment of America’s job seekers by the
US Department of Labor,
the 1992 Na-
tional Adult Literacy Survey,
and the
International Adult Literacy Surveys that
were conducted over 3 cycles involving
more than 20 countries and language
All items in the surveys were coded as
health or as non-health related as part of
what is later referred to as the Health
Activities Literacy Study (HALS). Over
230 health-related items were distilled
from the surveys and coded as belonging
to 1 of 5 categories of health activities, as
noted above. Of these, 191 were used in
US surveys. These 191 health activities
and literacy items were constructed as a
health literacy scale for US analyses. We
turn first to the features of the adult
literacy surveys and then to the coding
process and the characteristics of the
health literacy scale.
Characteristics of Health Items on
Adult Literacy Surveys
The study of adult health literacy builds
on the national and international sur-
veys of adult literacy, all of which adopted
the same functional definition of literacy:
Using printed and written information
to function in society, to achieve one’s
goals, and to develop one’s knowledge
and potential.
The measures of adult literacy are
based on the premise that adults do not
read printed or written materials in a
vacuum but instead turn to materials for
a specific purpose. The education schol-
ars who crafted these surveys focused on
people’s ability to use print materials
commonly found in everyday life to ac-
complish mundane tasks. Efforts were
made to select a broad range of materials
within a wide range of relevant contexts
and contents and avoid specialized mate-
rials familiar only to particular groups.
Thus, materials for the various large-
scale adult literacy surveys were drawn
from 6 domains of everyday life: home and
family, health and safety, community and
citizenship, consumer economics, and
work, as well as leisure and recreation.
The materials used in the surveys
varied by type and consisted of prose and
documents, as well as both continuous
and noncontinuous texts requiring 1 or
more arithmetic operations. For example,
materials included a newspaper article
(continuous text), a weather chart (docu-
ment), a work benefit package (continu-
ous text), as well as a bank deposit slip (a
table) and an advertisement for a 10% off
sale at a supermarket (text with num-
bers). The tasks were organized into 3
major categories—locate information,
integrate information, and generate in-
formation—and were designed to simu-
late the specific tasks that people com-
monly undertake in daily life.
document, and quantitative literacy as
well as the associated texts and tasks are
described in more detail in Table 1.
All of the adult literacy surveys were
constructed around everyday materials
focused on everyday types of tasks. An
adult with asthma may use a weather
report to make decision about the day’s
activities. A parent may consult a chart
on a package of over-the-counter medi-
cine to determine correct dosage for a
child of a specific age or weight. A worker
may need to use a pay stub to locate
information needed on an insurance ap-
plication. The example provided in Figure
1 is taken from a label on an over-the-
counter pediatric medicine, in use in the
1990s. This material has component parts
in prose and document format, and it also
contains numbers. It provides a good il-
Health Literacy in the U.S.
lustration of different types of tasks at
varying levels and is discussed, in detail,
in Literacy and Health in America.
The final set of items and scoring for
the HALS adapted the format and struc-
ture of the National Adult Literacy Survey
(NALS) of 1992, which was conducted with
a sample of 26,091 adults age 16 and
Scores for the NALS and the other
large-scale surveys from which the health
items were drawn ranged from 0 to 500
and were characterized in terms of 5
levels, used to represent the progression
of complexity and difficulty of the tasks
along the literacy scales. The authors
used the same scale, range, and levels for
the HALS analysis.
Health-related Materials and Tasks
The organizing framework used for the
coding and analysis spans various health
tasks such as purchasing food and prod-
ucts, using products at home or at work,
interpreting information about air and
water quality, using medicine, applying
for insurance, and offering informed con-
sent. Table 2 provides a list of these
categories with selected examples of
materials and tasks. Trained research
assistants independently coded all mate-
rials and questions. All differences were
resolved through discussions and refine-
ment of the coding criteria.
In all, 191 literacy tasks were judged to
measure health-related activities across
U.S. surveys. Those items used only on
the International Adult Literacy Survey
(IALS) or only on the Adult Literacy and
Learning Survey (ALLS) were not included.
The coded items represent important
aspects of health literacy across the 5
contexts; 60 items addressed health pro-
motion, 65 were on health protection, 18
items were on disease prevention, 16
Table 1
Literacy Texts and Tasks
Literacy Examples of
Type Description Text Types Tasks
Prose Knowledge and Editorials, news stories, poems, The prose tasks associated
skills needed to read and fiction. These texts types with these texts include finding
and understand vary and include descriptive, a piece of information in a
materials that are expository, argumentative, newspaper article, interpreting
formed of sentences and instructive types. instructions from a warranty,
organized into inferring a theme from a poem,
paragraphs. or identifying the contrasting
views expressed in an editorial.
Document Knowledge and skills Tables, charts, graphs, maps, Tasks associated with the use
required to locate and and forms. These texts include of documents include using a
to use information maps, job applications, chart to determine the correct
contained transportation schedules and dosage of medicine based on
payroll forms. age and weight, using a schedule
to choose the appropriate bus,
or entering information on an
application form.
QuantitativeKnowledge and Use of numbers embedded in Tasks require one or more
skills needed to be print materials formatted as arithmetic procedures based on
able to apply either prose or document texts. information in the text.
arithmetic operations, Examples of tasks include
either alone or balancing a checkbook,
sequentially. figuring out a tip, completing an
order form, or determining the
amount of interest from a loan
Am J Health Behav.
2007;31(Suppl 1):S8-S18
concerned health care and disease man-
agement, and 32 items addressed naviga-
tion. Health promotion and health protec-
tion items constitute the bulk of the items
(n=125). Only 66 of the items [activities
under prevention, care and management,
and navigation] represent activities re-
lated to health care settings. Thus, the
set of 191 items was not distributed evenly
across each of the 5 health activities.
The psychometric behavior of each item
was checked as was the fit of each item
into the overall scale used for the HALS
analysis. More than 58,000 respondents
from across the various adult surveys
were used to estimate and verify the
health-related literacy item parameters.
However, because the focus of this in-
quiry was the US adult population, the
health activities literacy study used only
population samples from the United
The procedure to align the health lit-
eracy activities scores with the NALS was
based on matching 2 moments of the
proficiency distributions – the mean and
standard deviation. The link between
HALS and NALS contributes to the valida-
tion of the HALS, and correlations were
examined between HALS and a wide range
of background characteristics that in-
clude age, gender, race/ethnicity, level of
education, country of birth, health status,
and wealth. Final HALS scores are pro-
Figure 1
Pediatric Medicine Label
Health Literacy in the U.S.
vided as a composite score of prose, docu-
ment, and quantitative literacy.
The average overall score of 272 (with a
standard deviation of 61) on the HALS is
similar to the average scores on the 3
literacy scales reported in the NALS. Fig-
ure 2 provides an illustration of HALS
proficiencies, overall and by gender. There
is little illiteracy in the United States. How-
ever, 19% of the adult population performs
in the lowest of the 5 levels on the HALS,
indicating difficulty using relatively simple
texts. Of these, 7% are estimated to be
performing at the bottom of this level and
thus are unable to perform even simple
tasks with a high degree of proficiency.
There is no significant difference between
men (average score of 272) and women
(average score of 271) on the HALS.
An additional 27% of adults are esti-
mated to be performing in Level 2 on the
HALS. Together, some 46% of the adult
population (levels 1 and 2 combined) is
estimated to have restricted health lit-
eracy proficiencies in that they are per-
forming below the average proficiencies of
adults who terminated their education with
a high school diploma or GED. As is illus-
trated in Figure 3, adults who have not
completed high school or earned a GED
have an average score on the HALS of 220,
or at the upper end of Level 1. Those who
either graduated from high school or earned
their GED achieved an average score of
Table 2
Health Activities Framework With Selected Examples
Activities Content Focus Examples of Materials Examples of Tasks
Health Promotion Enhance & Articles in newspapers and Purchase drinks with low
maintain health magazines, booklets, sugar content
brochures, charts, graphs, Plan exercise daily regimen
lists, food and product labels
Health Safeguard health Articles in newspapers and Decide among product
Protection of individuals & magazines, postings for health options
communities and safety warnings at work Follow safety precautions
or in the community, air and Vote
water quality reports,
Disease Take preventive News alerts [TV, radio, Determine risk
Prevention measures & engage papers], postings for inocula- Engage in screening or
in early detection tions & screening, letters with diagnostic tests
test results, graphs, charts Purchase food with low
Make a follow-up
Health Care Seek care & form a Health history forms, medicine Describe & measure
& Maintenance partnership with labels, discharge instructions, symptoms
health providers education booklets & brochures Follow directions on medicine
Calculate timing for medicine.
Systems Access needed Maps, Application forms, Locate facilities,
Navigation services statements of rights and Apply for benefits
Understand rights responsibilities, informed Offer informed consent
consent, benefit packages
Am J Health Behav.
2007;31(Suppl 1):S8-S18
271; those who continued their education
beyond high school obtained an average
score 306 and those who continued their
education beyond high school obtained an
average score of 306.
Differences in proficiency scores by
age were evident as well. The average
health-related skills of younger popula-
tions are significantly higher than those
of older adults. Those over the age of 65
have an average HALS score of 224 com-
pared to 287 for those 30-45 years of age
and 282 for those 16-29. However, HALS
scores differ among older adults based on
education, health status, and wealth.
Table 3 provides an overview of HALS
proficiency among older adults by selected
characteristics. Older adults with educa-
tional achievement beyond high school
level and with access to resources have
higher literacy skills than do those with-
out such background or resources.
When nativity is considered, the aver-
age HALS proficiency for adults born in
the United States is 278 compared to the
overall average of 272. HALS proficiency
scores among non-native-born adults are
significantly below that of the native-born
adult population. The average proficiency
of European Americans (white) on the
HALS is significantly higher than are the
average proficiency of African Americans
(black), Hispanic Americans, and other
groupings of adults living in the United
States. African American adults have an
average HALS score of 239 and Hispanic
American adults have an average of 217.
However, among Hispanic American
adults born in the United States, the
average HALS score is 256.
Findings indicate that adults with lim-
ited health literacy proficiencies are gen-
erally those who have not completed high
school or obtained a GED, have health-
related restrictions on their ability to
attend school or work, are members of
minority or marginalized population
groups, and/or who have immigrated to
12 12
Total Population (272) Male (272) Female (271)
HALS Levels
Percentage in Level
Figure 2
Overall HALS Findings and by Gender
Health Literacy in the U.S.
the United States. Furthermore, those
with limited health literacy proficiencies
are likely to report living in poverty with
no income from savings, dividends, or
retirement. Table 4 provides an overview
of mean HALS proficiency by wealth sta-
tus and level of education. Latent class
analyses yielded portraits of groups of
adults who are likely to have limited
health literacy proficiency. Adults with
limited health literacy proficiencies are
more likely to report reading little prose
and no documents and are more likely to
rely on television as a primary source of
information than are adults with higher
The analysis presented here is based
on the 191 health-related tasks used
across several literacy surveys, ranging
from simple to complex, and representing
tasks undertaken in each of 5 health
activities delineated in the health lit-
eracy framework. The IOM health lit-
eracy report recommends a broad under-
standing of when and where adults take
action related to their health. Attention
to multiple health contexts moves beyond
a vision of adults as patients and consid-
ers a full spectrum of health-related ac-
tivities of daily life.
The study findings offer an initial ex-
amination of health literacy proficiency
that moves beyond assessments of mate-
rials, word recognition skills, or reading
comprehension. The analysis of health
literacy proficiencies indicates that the
distribution of health literacy is not inde-
pendent of general literacy skills at a
population or subpopulation level. Al-
though there is clearly some unique pro-
cedural and declarative knowledge that is
needed to function in health contexts,
those with more general literacy skills
will also be more likely to have stronger
health literacy skills.
Expectations of and literacy-related
0.5 0.5
Less than High
School (Mean 220)
High School or GED
(Mean 271)
Beyond High School
(Mean 306)
HALS Levels
Percentage in Level
Figure 3
HALS Proficiencies by Educational Attainment
Am J Health Behav.
2007;31(Suppl 1):S8-S18
demands on the US adult population are
increasing in all sectors, including the
health sector. This increase in demands
is associated with the diffusion of infor-
mation and communication technologies
and with an increased expectation that
individuals need to accept more responsi-
bility for acquiring and using information
related to many aspects of their lives.
Unfortunately, in face of these increases
in demands and expectations, the find-
ings from the 2003 National Assessment
of Adult Literacy (NAAL) indicate there
has been little improvement of adult skills
over time — from the first national survey
of adult literacy skills in 1992 to that
conducted during the first decade in the
new century. Instead, evidence points to
lower proficiencies.
Comparison Between HALS and NAAL
Health Literacy Report
The examination of all items from the
NALS and other large-scale literacy sur-
veys enabled the authors to identify a
wide range of health-related materials
and tasks. The health-related materials
were collected as part of a sample of ma-
terials gathered to represent various do-
mains of everyday life. A thorough analy-
sis and coding of all health-related items
supported an investigation into health
literacy skills.
The more recent 2003 NAAL included a
purposive sample of materials and items
related to health. The US Department of
Health and Human Services worked with
the Department of Education to insert a
number of specific health related items to
be analyzed independently and so serve
as a measure of progress for the health
literacy objective in Healthy People 2010
and subsequent years. Consequently, 28
new items related to 3 domains of health
and health care information and services
were added to the literacy assessment
tool. These items represented 3 domains
labeled clinical, prevention, and naviga-
tion of the health care system. Each of the
28 items followed the same format and
structure of other materials and tasks on
the literacy tool as discussed earlier and
so included prose, document, and quanti-
tative items.
Although the 2 analyses
are not directly comparable, they are based
on the same conceptualization of func-
tional literacy and the same structure of
Table 3
HALS Proficiency Among
Older Adults by Selected
Characteristics of Adults Mean SD
>65 224 60
By Education Level
Less than High School 192 54
High School or GED 240 44
Beyond High School 268 45
By Health Status
Limiting condition 198 57
No limiting condition 236 57
By Poverty Status
Poor/Near Poor 193 55
Not Poor 242 54
By Whether They
Receive Dividends
No 210 57
Yes 256 51
Table 4
HALS Proficiency by Wealth
and Education
Mean Mean Mean
Score Score Score
Working adults
[with assets] 273 291 321
Working adults
additional assets] 218 267 293
[with assets] 216 257 285
[without assets] 217 264 281
[in poverty
without assets] 188 240 261
Health Literacy in the U.S.
materials and tasks.
In addition, several changes were made
in the analytic processes for the 2003
NAAL data. These changes were related
to the sampling parameter, to the perfor-
mance levels used to identify and charac-
terize the participants, and in the level
set for the probability of doing a task
correctly. In brief, the analysis of the
NAAL data does not include 3% of the
population who were unable to answer a
background questionnaire because of in-
ability to read in English or in Spanish or
because of a mental disability. Next, new
performance levels, deemed more appro-
priate and useful for education policy were
used instead of the NALS 1 through 5
levels. The new levels are labeled below
basic, basic, intermediate, and proficient.
These labels were developed to help adult
education policy makers to identify per-
formance levels and needed programs.
Finally, although the NALS mapped items
to a performance level of 80% likelihood of
getting an item correct, the NAAL used
the 67% probability convention.
As a
result, a comparison of the NAAL health
literacy findings with the HALS findings
published here are even more cumber-
some. At the same time, the results of
both do indicate ongoing serious prob-
The National Center for Education Sta-
tistics announced health literacy find-
ings in September 2006. Fully 53% of US
adults have health literacy scores in the
intermediate range, a category indicating
needed skill building. Fourteen percent of
adults scored at below basic level; an
additional 22% scored at the basic level;
and 12% scored in the proficient level.
The report indicates that the average
health literacy score for high school gradu-
ates was 232 on a 0 to 500 score range.
Women scored higher than men with an
average health literacy score of 248 com-
pared to 242 for men. Those over 65 years
of age had a health literacy mean score of
214 (the lowest average score) compared
to a mean score of 256 for adults between
the age of 25 and 39 (the highest average
score). The report, The Health Literacy of
America’s Adults: Results from the 2003
National Assessment of Adult Literacy, will
be considered the baseline measure of
health literacy
for measuring attain-
ment of health literacy objectives.
Overall, the average scores reported for
the NAAL health literacy measure are
lower than those for general literacy
among adults as measured by the NAAL
and the average scores for the HALS. In
2006, the conclusion remains the same:
large numbers of US adults do not have
health literacy skills that would enable
them to effectively use complex health
materials to accomplish challenging or
complex health-related literacy tasks.
The adult education sector’s focus on
proficiencies related to the use of materi-
als to accomplish health-related tasks
offers insight to those of us concerned
with health literacy. First, the adult lit-
eracy surveys bring our attention to the
many different types of health-related
texts developed for adults and to the char-
acteristics of texts that enhance or im-
pede actual use. The format and struc-
ture of different types of texts may influ-
ence adults’ ability to carry through with
critical tasks and thereby accomplish
important activities.
Print and on-line guidebooks and a
variety of measurement tools offer sug-
gestions for the development of health
materials designed to ease reading, com-
prehension, and retrieval of information
and instructions.
The analysis of text
characteristics and measures of difficulty
applied to the development of the adult
literacy surveys add further insight. Dis-
tracting information, complex documents,
a partial provision of needed information
or instructions — all inhibit one’s ability
to use print materials with ease and
Health communicators need a thor-
ough understanding of text characteris-
tics in order to craft messages, develop
information booklets, delineate proce-
dures and instructions, and provide criti-
cal information related to rights and con-
sent. Formative research processes and
procedures are well established and
readily available to those who develop
health materials.
myriad studies indicate that such in-
sights, guidelines, and research rigor are
often not followed or implemented for the
development of health materials. Cer-
tainly, no professional ought to sign off on
materials that have not undergone rigor-
ous formative evaluation including re-
views and piloting with members of the
intended audiences. In light of findings
related to medical errors as well as to
Am J Health Behav.
2007;31(Suppl 1):S8-S18
outcomes related to limited reading abili-
ties, the health field can no longer toler-
ate casually or carelessly written materi-
als and documents.
Adults trying to apply health informa-
tion would benefit from clear and straight-
forward written and oral communication
and from improvements in the design of
charts and graphs. They might benefit
even more if materials were designed,
not only to provide information, but with
specific actions and tasks in mind. Mate-
rials designed from the perspective of the
user, based on a clear understanding of
the purpose the materials serve and the
tasks adults need to undertake, could
lessen the burden on the user.
Consequently, a second valuable in-
sight emerges from the analyses of the
format and structure of the adult literacy
surveys. These surveys bring our atten-
tion to a wide variety of mundane tasks –
those essential health tasks that cause
adults to read and use a wide range of
materials. In order to undertake an analy-
sis of task characteristics and measures
of difficulty, those in the health field must
first break down activities into specific
tasks. For example, the act of taking
medicine involves several tasks. These
tasks may include differentiating between
2 medicines, using a clock to determine
time between doses, and using a calendar
to plan a schedule or make note of needed
renewal time. Many of these tasks re-
quire sophisticated literacy skills.
materials, meant to serve as tools for
needed action, must be linked to the
tasks adults are expected to engage in
and must be carefully and specifically
crafted to support such tasks.
Adults with limited literacy skills face
the same health-related challenges as
adults with strong literacy skills. They too
need to establish a healthy diet, main-
tain a healthy lifestyle, take care of their
family, engage in safe work practices,
and contribute to the well-being of their
communities. They are faced with new
information, are asked to understand and
take action in face of new diseases and
new therapies. In addition, they are often
provided with unnecessarily complex
materials that do not function as the tools
and aids they are meant to be.
Furthermore, differences in literacy
proficiencies based on educational attain-
ment, poverty, access to resources, and on
majority versus minority status indicate
powerful effects of social factors. These
findings set a foundation for future exami-
nations of literacy and health literacy as a
mediating factor in health disparities.
Finally, this analysis indicates that
increases in health may be linked to a
stronger investment in education, most
especially in poor and disadvantaged com-
munities. At the same time, educational
opportunities for health professionals,
administrators, and communicators need
to be expanded and must include a clear
understanding of health literacy, an
awareness of existing health literacy
skills among US adults, and a simulta-
neous recognition of the very high expec-
tations and demands within our society.
The author thanks Michael Wolf for his
guidance and keen editing and Irwin
Kirsch and Kentaro Yamamoto for their
insight and generosity.
1.Rudd RE, Anderson JE, Nath C, et al. Health
literacy: an update of medical and public
health literature. In Comings JP, Garner B,
Smith C (Eds.), Review of Adult Learning and
Literacy, Vol 7. Mahwah, NJ: Lawrence
Erlbaum Associates 2007:175-203.
2.Berkman ND, DeWalt DA, Pignone MP, et al.
Literacy and health outcomes. Evidence Re-
port/Technology Assessment No. 87. AHRQ
Publication No. 04-E007-2. Rockville, MD:
Agency for Healthcare Research and Quality
3.Rudd RE, Moeykens BA, Colton TC. Health
and literacy: a review of medical and public
health literature. In Comings JP, Garner B,
Smith C (Eds.), The Annual Review of Adult
Learning and Literacy. San Francisco, CA:
Jossey-Bass Publishers 2000:158-199.
4.Rudd RE. Objective 11-2 Improvement of health
literacy. In US Department of Health and
Human Services. Communicating Health: Pri-
orities and Strategies for Progress—Action
Plans to Achieve the Health Communication
Objectives in Healthy People 2010. Washing-
ton, DC: US Government Printing Office
5.Institute of Medicine. Health Literacy: A Pre-
scription to End Confusion. Washington DC:
The National Academies Press 2004.
6.Kirsch IS, Jungeblut A. Literacy Profiles of
America’s Young Adults. Princeton, NJ: Edu-
cational Testing Service 1986.
7.Kirsch IS, Jungeblut A, Campbell A. Beyond
the School Doors: The Literacy Needs of Job
Seekers Served by the US Department of
Labor. Princeton NJ: Educational Testing
Service 1992.
8.Kirsch IS, Jungeblut A, Jenkins L, et al. Adult
Health Literacy in the U.S.
Literacy in America: A First Look at the
Results of the National Adult Literacy Survey.
Washington, DC: National Center for Educa-
tion Statistics 1993.
9.Organisation for Economic Co-Operation and
Development, & Statistics Canada. Literacy,
Economy, and Society: Results of the First
International Adult Literacy Survey. Ottawa:
Statistics Canada 1995.
10.Organisation for Economic Co-Operation and
Development, & Statistics Canada. Literacy in
the Information Age. Ottawa: Statistics Canada
11.Kirsch IS. The International Adult Literacy
Survey: Understanding What Was Measured.
Princeton, NJ: Educational Testing Service
12.Rudd RE, Kirsch IS, Yamamoto K. Literacy
and Health in America. Princeton, NJ: Educa-
tional Testing Service 2004.
13.Kutner M, Greenberg E, Baer J. A First Look
at the Literacy of America’s adults in the 21
Century (NCES 2006-470). US Department of
Education. Washington, DC: National Center
for Education Statistics 2005.
14.Kutner M, Greenberg E, Jin Y, et al. The
Health Literacy of America’s Adults: Results
from the 2003 National Assessment of Adult
Literacy (NCES 2006-483). US Department of
Education. Washington, DC: National Center
for Education Statistics 2006.
15.National Research Council. Measuring Lit-
eracy: Performance Levels for Adults. Com-
mittee on Performance Levels for Adult Lit-
eracy, Houser RM, Edley CF Jr., Koenig JF et
al. (Eds). Board on Testing and Assessment
Center for Education. Division of Behavioral
and Social Sciences and Education. Washing-
ton, DC: The National Academies Press 2005.
16.Doak CC, Doak LG, Root JH. Teaching Pa-
tients with Low Literacy Skills (2
ed.). Phila-
delphia, PA: J.B. Lippincott Company. 1996
(online). Out of Print. Available at: Ac-
cessed January 23, 2007.
17.Centers for Disease Control and Prevention.
Simply Put (online). 1999. Available at: http:/
/ Accessed
January 23, 2007.
18.National Cancer Institute. Making Health
Communication Programs Work: A Planner’s
Guide. NIH Publication No. 04-5145. 2001.
Reprinted August 2004.
19.Szudy E, Arroyo MG. The Right to Understand:
Linking Literacy to Health and Safety Training.
Berkeley, CA: University of California Press
20.Rudd RE, Soricone L, Santos M, et al. Health
literacy study circles: Introduction (online).
Boston MA: National Center for the Study of
Adult Leaning and Literacy 2005. Available at: Accessed January 23, 2007.
... Similarly, female students may be more critical about the information and scored lower on these subscales. Nevertheless, there is no clear evidence about the associations between gender and health literacy [33][34][35][36][37]. Since low health literacy is associated with a lower socioeconomic condition [33,37,38]-even in the context of online health information the associations of DHL with socioeconomics remain significant [39]-we included a proxy measure of subjective social status [23] as a potential confounder along with education (e.g., the degree of studies and course). ...
... Similarly, female students may be more critical about the information and scored lower on these subscales. Nevertheless, there is no clear evidence about the associations between gender and health literacy [33][34][35][36][37]. Since low health literacy is associated with a lower socioeconomic condition [33,37,38]-even in the context of online health information the associations of DHL with socioeconomics remain significant [39]-we included a proxy measure of subjective social status [23] as a potential confounder along with education (e.g., the degree of studies and course). ...
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We aimed to evaluate the associations between information searching about public health and social measures (PHSM) and university students' digital health literacy (DHL) related to the new coronavirus (SARS-CoV-2) and COVID-19. Methods: This cross-sectional study included 3,084 Portuguese university students (75.7% females), with an average age of 24.2 (SD = 7.5). Sociodemographic data, DHL questionnaire and online information concerning PHSM were gathered. Cox proportional hazards models were performed. Results: Students who searched for personal protective measures achieved in shorter time sufficient "evaluating reliability" (HR = 1.4; 95% CI = 1.1; 1.7) and "determining relevance" (HR = 1.5; 95% CI = 1.2; 1.8). Searching for surveillance and response measures was associated with sufficient "determining relevance" (HR = 1.4; 95% CI = 1.1; 1.9). Finally, those students who searched for environmental, economic and psychosocial measures achieved in shorter time "determining relevance" (HR = 1.2; 95% CI = 1.0; 1.4). Conclusions: Searching for PHSM was significantly associated with an increased likelihood of achieving sufficient DHL subscales in a shorter time. Further studies are needed, including developing strategies to increase the availability of high-quality information concerning public health and social measures and to improve (digital) health literacy.
... Countries with a higher educational level spend less on average. It has been confirmed by many authors that higher education is correlated to higher health literacy (Rudd 2007). Individuals with a high level of education might be better orientated in the use of health services and likely to consume resources more consciously. ...
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This study aims to investigate the association between gross domestic product (GDP), mortality rate (MR) and current healthcare expenditure (CHE) in 31 high-income countries. We used panel data from 2000 to 2017 collected from WHO and OECD databases. The association between CHE, GDP and MR was investigated through a random-effects model. To control for reverse causality, we adopted a test of Granger causality. The model shows that the MR has a statistically significant and negative effect on CHE and that an increase in GDP is associated with an increase of CHE (p < 0.001). The Granger causality analysis shows that all the variables exhibit a bidirectional causality. We found a two-way relationship between GDP and CHE. Our analysis highlights the economic multiplier effect of CHE. In the debate on the optimal allocation of resources, this evidence should be taken into due consideration.
... The participants of this study were college students aged between 17 and 26, while the subjects of Bernard et al. were the elderly people. Rudd [37] thought that aging would affect reading skills. As they got older, their eyesight was weakening. ...
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Learning through video is an important learning method at present. In various teaching videos, subtitle size varies greatly. Therefore, it is essential to evaluate the influence of subtitle size on different teaching videos. In this paper, 90 college students from a Chinese University were randomly divided into three groups: small subtitle teaching video group, middle subtitle teaching video group and large subtitle teaching video group. The experiment was conducted to explore the effect of subtitle size on learners’ cognitive load, academic performance, and learning satisfaction. The results showed that: (1) compared with the large subtitle teaching video, learners had lower cognitive load when watching small and medium subtitles teaching videos; (2) compared with the large subtitle teaching video, the learners who watched the small subtitle teaching video had better performance; (3) compared with the large subtitle teaching video, the learners who watched the small and medium subtitle teaching video had higher learning satisfaction. Based on these results, this paper emphasizes the importance of subtitle size in teaching video. We suggest that the relevant departments should further refine the production standards of teaching videos; teachers should try to make teaching videos with smaller subtitles; students should choose teaching videos with smaller subtitles; researchers and technical teams should strengthen the research and development of personalized subtitle technology, so as to allow the private customization of subtitle size based on learners’ needs and preferences.
... This well-established confluence of socioeconomic risk factors led to the statement by Samuel A. Broder, director of the National Cancer Institute (NCI) in 1989, that "poverty is a carcinogen" (1991). Poverty is also associated with unequal access to education and lower health literacy (Rudd, 2007), exacerbating the informed consent challenges in cancer care discussed previously. Longstanding racial inequality means that communities of color experience these socioeconomic barriers to cancer care at disproportionately high rates (Morris et al., 2010). ...
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Numerous ethical issues are raised in cancer treatment and research. Informed consent is challenging due to complex treatment modalities and prognostic uncertainty. Busy oncology clinics limit the ability of oncologists to spend time reinforcing patient understanding and facilitating end-of-life planning. Despite these issues and the ethics consultations they generate, clinical ethicists receive little if any focused education about cancer and its treatment. As the field of clinical ethics develops standards for training, we argue that a basic knowledge of cancer should be included and offer an example of what cancer ethics training components might look like. We further suggest some specific steps to increase collaboration between clinical ethicists and oncology providers in the outpatient setting to facilitate informed consent and proactively identify ethical issues.
... Despite the well documented evidence of limited or low literacy and numeracy skills among adults in the U.S. [9], insufficient action has been taken by those of us preparing and disseminating scientific-, environmental-, and health-related information. For example, over a decade after the first adult literacy analyses were made available in the U.S. in 1993, more than 2000 peer reviewed health literacy studies indicated that health materials are generally written at levels of complexity far beyond the reading skills of average highschool graduates [10]. ...
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Successful dissemination of scientific knowledge relies on the ability of the writer, speaker, and designer to provide information and data that is both available and accessible to the audience for whom it is intended. Scientific rigor, uniformly applied to the development of medicines, products, and devices must be applied, as well, to communications—spoken, written, posted, or displayed. Rigorous development and design protocols call for formative research data gathering, careful pilot testing with members of the intended audience, needed revisions, and rigorous assessments. Guidelines and tools developed for health literacy applications can be adopted and adapted for environmental health research and educational efforts in the design of questionnaires, instructions, education and report back materials, as well as for public discourse.
À l’île Maurice, plus d’une personne sur cinq est touchée par le diabète, d’où l’enjeu important que représente le développement de l’éducation à la santé en population. Les travaux scientifiques menés à l’international soulignent en effet la pertinence d’un travail sur l’accès et la compréhension des informations en santé, avec des prises de décision contextualisées. Menées dans de nombreux pays, les recherches sur la littératie en santé montrent aussi la contribution des actions éducatives à la réduction des maladies non-transmissibles, en particulier dans le domaine du diabète de type 2. Inscrite dans les Sciences de l’éducation et de la formation, notre recherche doctorale interroge les conditions du développement de la littératie en santé auprès d’étudiants de l’Université, à Maurice. Les atouts et les limites sont analysés en lien avec des interventions éducatives proposées à 48 étudiants en Informatique. À travers un processus de Recherche-Intervention qui met en jeu les « nids d’apprentissage », nous interrogeons les conditions d’un travail sur les dimensions biomédicales et psychosociales de la santé qui prend en compte les apports du socioconstructivisme et de l’«empowerment » en contexte. Sur le plan méthodologique, nous croisons des données quantitatives recueillies à partir de 234 questionnaires multidimensionnels HLQ (Health Literacy Questionnaire) avec des données qualitatives (observations, entretiens), ce qui permet d’analyser les savoirs travaillés lors des interventions éducatives et leurs possibles appropriations par les étudiants. Les résultats soulignent le faible niveau général des étudiants mauriciens en littératie en santé. Ils montrent aussi comment des interventions éducatives pourraient permettre de développer, à Maurice, l’accès et compréhension de l’information en santé ainsi que la prise de décisions en faveur d’une prévention des pathologies chroniques. Ils soulignent enfin les atouts et les limites des méthodologies mixtes, notamment dans les recherches en littératie en santé, en plein essor actuellement.
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(1) Background: The importance of physician-patient communication and its effect on patient satisfaction has become a hot topic and has been studied from various aspects in recent years. However, there is a lack of systematic reviews to integrate recent research findings into patient satisfaction studies with physician communication. Therefore, this study aims to systematically examine physician communication’s effect on patient satisfaction in public hospitals. (2) Methods: Using a keywords search, data was collected from five databases for the papers published until October 2021. Original studies, observational studies, intervention studies, cross-sectional studies, cohort studies, experimental studies, and qualitative studies published in English, peer-reviewed research, and inpatients who communicated with the physician in a hospital met the inclusion criteria. (3) Results: Overall, 11 studies met the inclusion criteria from the 4810 articles found in the database. Physicians and organizations can influence two determinants of inpatient satisfaction in physician communication. Determinants of patient satisfaction that physicians influence consist of amounts of time spent with the patient, verbal and nonverbal indirect interpersonal communication, and understanding the demands of patients. The organization can improve patient satisfaction with physician communication by the organization’s availability of interpreter service and physician workload. Physicians’ communication with inpatients can affect patient satisfaction with hospital services. (4) Conclusions: To improve patient satisfaction with physician communication, physicians and organizational determinants must be considered.
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High-quality patient information material (PIM) is essential for patients´ informed decision-making, and its quality may influence a care program’s acceptance. In the new psycho-oncological care program, isPO, the initial PIM was developed top-down and required optimization. In this paper, we report on the process and experiences of optimizing PIM’s quality bottom-up by applying a Participatory Health Research (PHR) approach. Cancer-patient representatives of the national peer-support group contributed as co-researchers as part of the optimization team. A mixed-methods design was chosen. First, the quality of the initially utilized PIM was assessed with the newly designed user-friendly instrument UPIM-Check. Next, three Participatory Action Research loops were conducted, including cancers survivors and isPO service providers. The initial isPO PIM’s were assed to be of low quality, limited usability and incomplete. Bottom-up generated optimization suggestions led to the improvement of two initially used PIMs (leaflet, patient information folder) and the design of two new PIMs (poster, study information overview). The optimized PIM facilitates isPO service providers’ care provision and helps newly diagnosed cancer patients in understanding and accepting the new program. PIM optimization benefited from applying PHR. The patient representatives’ contribution and active patient engagement were central for quality assessment and designing needs-driven, mature and complete PIM.
This paper offers a framework that has been used for both developing the tasks used to measure literacy and for understanding the meaning of what has been reported with respect to the comparative literacy proficiencies of adults in participating countries. The framework consists of six parts that represent a logical sequence of steps, from needing to define and represent a particular domain of interest, to identifying and operationalizing characteristics used to construct items, to providing an empirical basis for interpreting results. The various parts of the framework are seen as important in that they help to provide a deeper understanding of the construct of literacy and the various processes associated with it. A processing model is proposed and variables associated with performance on the literacy tasks are identified and verified through regression analyses. These variables are shown to account for between 79% and 89% of the variance in task difficulty. Collectively, these process variables provide a means for moving away from interpreting performance on large-scale surveys in terms of discrete tasks or a single number, toward identifying levels of performance that have generalizability across pools of tasks and toward what Messick (1989) has called a higher level of measurement.
This manual introduces health and safety trainers to the experiences and training needs of workers with limited literacy skills and provides tools and practical tips for developing materials and programs with literacy in mind. Chapter 2 introduces literacy issues through the stories of six workers and links literacy issues with health and safety concerns. Chapter 3 discusses how to link literacy to needs assessment and how to use results to improve materials and training. Chapter 4 describes how to write materials that are easy to read, visually appealing, and use illustrations to help explain the text. Chapter 5 covers using a checklist to evaluate materials, readability formulas, and focus groups to field test materials. Chapter 6 addresses adapting training methods to reach participants with a range of literacy skills. It presents sample activities for nine different participatory training methods, discuses their advantages and disadvantages, and offers tips for using them with literacy in mind. Chapter 7 presents reasons for testing participants' health and safety knowledge and skill level, offers tips for developing a skills assessment, and provides skills assessment models that involve minimal reading and writing. Chapter 8 discusses experimenting with innovative ways to make health and safety information more accessible to workers, advocating for change, and promoting and participating in literacy programs. Resources appear at the end of each chapter. Contains 54 references. (YLB)
Individually administered literacy assessments were conducted with approximately 6,000 adults representing the 20 million persons served by the U.S. Department of Labor's (DOL) Employment and Training Administration through the Job Training Partnership Act (JTPA) or the Employment Service/Unemployment Insurance programs. Information-processing skills were measured in three areas key to the day-to-day management of life: prose comprehension skills, document literacy skills, and quantitative skills. Some of the findings of the study were the following: (1) people in the DOL programs who have higher levels of literacy skills tend to avoid long periods of unemployment, earn higher wages, and work in higher-level occupations than program participants with lower skills; (2) 40-50 percent of clients had literacy skills in the lowest 2 of the 5 defined literacy levels; (3) about one-fifth of the clients had literacy skills at the highest two defined levels; (4) Black and Hispanic populations were not different from each other, but they were disproportionately represented at both ends of the literacy scale compared to Whites; and (5) 35-40 percent of high school graduates tested scored in the lowest two levels of the scale. The following conclusions were reached: (1) outcome measures should ensure comparability across individuals and time periods; (2) literacy requirements of key job families should be identified; (3) individuals with low literacy levels will have limited success in job training programs and the job market; and (4) there is a significant need for adult education programs for low-literate persons. (KC)
In 1985 the National Assessment of Educational Progress (NAEP) assessed the literacy skills of America's young adults. The survey stressed the complexity and diversity of literary tasks in American society rather than using a simplistic single standard for literacy. NAEP convened panels of experts whose deliberations led to this definition of literacy: "using printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential." NAEP drew a nationally representative household sample of 21- to 25-year-olds living in the 48 contiguous states in the United States. Approximately 3,600 young adults in 40,000 households were interviewed and were assessed in performing tasks such as: (1) reading and interpreting prose; (2) identifying and using information located in documents; and (3) applying numerical operations to information contained in printed material. Major findings showed that while the overwhelming majority of young adults adequately perform tasks at the lower levels on three literacy scales (prose, document, and quantitative literacy), sizeable numbers appear unable to do well on tasks of moderate complexity. Included in the report are: (1) an overview and profiles of the estimated prose, document, and quantitative literacy proficiency of young adults at four levels of difficulty; (2) comparisons of young adults with in-school 17-year-olds; (3) characteristics of the young adults by race/ethnicity, years of education, and parental education; (4) relationships of background characteristics to performance levels on the proficiency scales; (5) oral language results for selected samples; and (6) a final section providing a summary and conclusions. (LMO)
trends; and report timely, useful, and high quality data to the U.S. Department of Education, the Congress, the states, other education policymakers, practitioners, data users, and the general public. 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 comments or suggestions about this or any other NCES product or report, we would like to hear from you. Please direct your comments to: National Center for Education Statistics Office of Educational Research and Improvement U.S. Department of Education 555 New Jersey Avenue, NW Washington, DC 20208--5651 September 1998 The NCES World Wide Web Home Page address is Suggested Citation U.S. Department of Education. National Center for Education Statistics. Evaluation of Definitions
Literacy and health outcomes
  • Nd Berkman
  • Da Dewalt
  • Mp Pignone
Berkman ND, DeWalt DA, Pignone MP, et al. Literacy and health outcomes. Evidence Report/Technology Assessment No. 87. AHRQ Publication No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality 2004.
National Center for the Study of Adult Leaning and Literacy Available at: Accessed
  • Ma Boston
Boston MA: National Center for the Study of Adult Leaning and Literacy 2005. Available at: Accessed January 23, 2007.
Health literacy study circles: Introduction (online)
  • Re Rudd
  • L Soricone
  • M Santos
Rudd RE, Soricone L, Santos M, et al. Health literacy study circles: Introduction (online).