Literacy and Health in America

This resource looks at literacy and health in America.

Rima Rudd
Irwin Kirsch
Kentaro Yamamoto
Author(s) Organizational Affiliation
Educational Testing Service
Publication Year
Resource Type
Informational Material

This report explores the relationship between literacy and health by re-examining data from two large-scale surveys of adult literacy conducted by ETS for the U.S. Department of Education: the National Adult Literacy Survey (NALS) and the International Adult Literacy Survey (IALS). Respondents in the large-scale assessments were asked to perform different literacy tasks based on a variety of health-related materials. In the current study, researchers analyzed performance results for these specific health-information-related tasks, and used the information to create a new Health Activities Literacy Scale (HALS), which was then linked to the NALS database.

The assessment surveys also gathered extensive background information about respondents' demographic and socioeconomic characteristics, as well as their health status, literacy practices, and civic participation. Using this information along with the new HALS scale, the authors estimate the distribution of literacy on health-related tasks among U.S. adults, describe the health literacy skills of at-risk or vulnerable population groups, and demonstrate how health-related literacy is connected to health status, wealth, and civic engagement.

What the experts say

This report can be useful to adult education practitioners by identifying and classifying the literacy skills that people need in order to interact with health information. This can then help them to better address health literacy in their programs and classrooms. It can also help the field by paving the way for new research in health literacy.

This report does have some limitations, including being based on data from 1992 and being based on a definition of health literacy that has since changed considerably. Yet at the same time, the report has contributed to the development of the concept and study of health literacy in some important ways. First, it identifies a framework for organizing health activities and classifies tasks used in the literacy assessments according to this framework. This provides a model for further study, although in the future the health-related tasks and activities identified should be re-examined, expanded, and possibly redistributed in their classification.

In addition, this report helps to expand the concept of health literacy as being more than simply about the role of individuals as patients in a medical facility.

Another valuable take-home benefit is the list of recommendations for future studies, many of which have yet to be fulfilled. If these recommendations are adopted widely, it will greatly move the field forward. For a summary of the recommendations, see the box below.

Recommendations for Future Study:

  • “Any future attempts to study health literacy need to take into account not only the range of materials associated with health literacy but also the kinds of processing that are required to understand and use the information contained in various parts of these materials, whether they are presented orally or in written form.”
  • Currently available and used measures are “reading assessment tools” that “do not constitute measures of health literacy. Health researchers will benefit from a rigorous measure of health literacy that goes beyond word recognition or reading comprehension to differentiate between prose and document literacy, to examine oral exchange, and to calibrate quantitative skills. … researchers have used various forms of these tools or made modifications in the tool itself or the scoring of the findings, making a comparison of findings across studies difficult.”
  • “The vast majority of literacy-related studies in the health fields has, to date, been narrowly focused on adults as patients and on their ability to read patient education and health care related materials.”
  • “A next step should entail a rigorous sampling of the range of health tasks. These tasks need to be identified across and within multiple health contexts and need to be calibrated.”
  • “In order to develop a more rigorous assessment of health literacy, greater insight is needed into the range of oral communications and written texts associated with various health-related activities. Thus, it may be useful to fund research studies that focus on the collection and analysis of such communications across various contexts and settings. A sampling of these tests could be analyzed in terms of vocabulary, content, or linguistic structure and compared across health-related activities or compared to those found in other contexts. Additional research could focus on the cognitive demands associated with various uses for these materials. The “tasks” or demands associated with these materials could also be compared with a more generic set of literacy tasks. Consequently, these analyses could serve as the basis for the development of new measures and assessments of health literacy.”
  • “… while limited literacy skills are important considerations, so too are the faulty assumptions or poor communication patterns of the health system.”