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Health Literacy: A Prescription to End Confusion
Lynn Nielsen-Bohlman, Allison M. Panzer, David A.

Kindig, Editors, Committee on Health Literacy
ISBN: 0-309-52926-3, 368 pages, 6 x 9, (2004)
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Committee on Health Literacy
Board on Neuroscience and Behavioral Health
Lynn Nielsen-Bohlman, Allison M. Panzer, David A. Kindig, Editors

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Support for this project was provided by the American Academy of Family Physi-
cians Foundation, California HealthCare Foundation, Commonwealth Fund, W.K.
Kellogg Foundation, MetLife Foundation, National Cancer Institute, Pfizer Corpo-
ration, and the Robert Wood Johnson Foundation. The views presented in this
report are those of the Institute of Medicine Committee on Health Literacy and are
not necessarily those of the funding agencies.
Library of Congress Cataloging-in-Publication Data

Health literacy : a prescription to end confusion / editors, Lynn Nielsen-Bohlman
... [et al.] ; Committee on Health Literacy, Board on Neuroscience and Behavioral
Health, [Institute of Medicine].
p. ; cm.
Includes bibliographical references and index.
ISBN 0-309-09117-9 (hardcover)—ISBN 0-309-52926-3 (pdf)
1. Health education—United States. 2. Literacy—United States.
[DNLM: 1. Health Education—methods—United States. 2. Health Educa-
tion—standards—United States. 3. Communication Barriers—United States. 4.
Educational Status—United States. WA 590 H4362 2004] I. Nielsen-Bohlman,
Lynn. II. Institute of Medicine (U.S.). Committee on Health Literacy.
RA440.H43 2004
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www.national-academies.org

COMMITTEE ON HEALTH LITERACY

DAVID KINDIG, (Chair), Wisconsin Public Health & Health Policy
Institute, University of Wisconsin at Madison
DYANNE D. AFFONSO, Faculty of Nursing, University of Toronto
ERIC H. CHUDLER, University of Washington School of Medicine
MARILYN H. GASTON, Assistant Surgeon General of the United States,
Retired
CATHY D. MEADE, University of South Florida College of Medicine
H. Lee Moffitt Cancer Center & Research Institute
RUTH PARKER, Emory University School of Medicine
VICTORIA PURCELL-GATES, Michigan State University
IRVING ROOTMAN, University of Victoria
RIMA RUDD, Harvard University School of Public Health
SUSAN C. SCRIMSHAW, School of Public Health, University of Illinois
at Chicago
BILL SMITH, Academy for Educational Development
Board on Neuroscience and Behavioral Health Liaisons

NANCY E. ADLER, Departments of Psychiatry and Pediatrics, University
of California, San Francisco
RICHARD G. FRANK, Department of Health Care Policy, Harvard
Medical School, Boston, MA
Board on Health Promotion and Disease Prevention Liaison

IRVING ROOTMAN, University of Victoria
Study Staff
LYNN NIELSEN-BOHLMAN, Study Director
ALLISON PANZER, Research Assistant
BENJAMIN N. HAMLIN, Research Assistant
ALLISON BERGER, Program Assistant
IOM Board on Neuroscience and Behavioral Health Staff

ANDREW M. POPE, Director
TROY PRINCE, Administrative Assistant
ROSA POMMIER, Finance Officer
JUDY ESTEP, Senior Program Assistant


Independent Report Reviewers
T
his report has been reviewed in draft form by individuals chosen for
their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s (NRC’s)
Report Review Committee. The purpose of this independent review is to
provide candid and critical comments that will assist the institution in
making its published report as sound as possible and to ensure that the
report meets institutional standards for objectivity, evidence, and respon-
siveness to the study charge. The review comments and draft manuscript
remain confidential to protect the integrity of the deliberative process. We
wish to thank the following individuals for their review of this report:
Moon Chen Jr., University of California, Davis School of Medicine

Linda C. Degutis, Yale University
Robert Graham, Agency for Healthcare Research and Quality
James Hyde, Tufts University School of Medicine
Irwin S. Kirsch, Educational Testing Service, Center for Global
Assessment
Randall W. Maxey, National Medical Association
Alan R. Nelson, American College of Physicians of Internal Medicine
Joanne Nurss, Georgia State University, Emeritus
Yolanda Partida, University of Southern California
Debra Roter, Johns Hopkins University
Although the reviewers listed above have provided many constructive

comments and suggestions, they were not asked to endorse the conclusions
vii

viii INDEPENDENT REPORT REVIEWERS
or recommendations nor did they see the final draft of the report before its
release. The review of this report was overseen by Daniel L. Azarnoff, D.L.
Azarnoff Associates, and Kristine Gebbie, Columbia University School of
Nursing. Appointed by the NRC and the Institute of Medicine, they were
responsible for making certain that an independent examination of this
report was carried out in accordance with institutional procedures and that
all review comments were carefully considered. Responsibility for the final
content of this report rests entirely with the authoring committee and the
institution.

Acknowledgments
T
he committee was aided in its deliberations by the testimony and
advice of many knowledgeable and experienced individuals, and the
efforts of a dedicated committee and staff. Consultants to the com-
mittee contributed ideas and report materials. The committee thanks con-
sultants Arlene Bierman, Agency for Healthcare Research and Quality;
John Comings, Harvard University; Terry Davis, Louisiana State University
Health Sciences Center; Julie Gazmararian, Emory University; David
Howard, Emory University; Frank McClellan, Temple University; Scott
Ratzan, Johnson and Johnson; Dean Schillinger, University of California at
San Francisco and San Francisco General Hospital Medical Center; Steve
Somers, Center for Health Care Strategies; and Barry Weiss, University of
Arizona.
The committee acknowledges with appreciation the testimony and other
assistance of many individuals committed to improving health literacy.
These individuals are Paul S. Appelbaum, University of Massachusetts Medi-
cal School; Cynthia Baur, U.S. Department of Health and Human Services;
Nancy Berkman, RTI International; Alvin Billie, The Gathering Place; Cindy
Brach, Agency for Healthcare Research and Quality; L. Natalie Carroll,
National Medical Association; Carolyn Clancy, Agency for Healthcare Re-
search and Quality; Eduardo Crespi, Centro Latino; Barbara DeBuono,
Pfizer Pharmaceuticals Group; Darren A. DeWalt, University of North
Carolina, Chapel Hill; Janice A. Drass, Centers for Medicare and Medicaid
Services, DHHS; Joyce Dubow, AARP Public Policy Institute; Lawrence J.
Fine, Office of Behavioral and Social Science Research, National Institutes
ix

x ACKNOWLEDGMENTS
of Health; Heng L. Foong, Pacific Asian Language Services for Health;

Robert Friedland, Georgetown University and Center on an Aging Society;
Robert Graham, Agency for Healthcare Research and Quality; Rita
Hargrave, University of California, Davis, and Veterans Medical Center of
Northern California System of Clinics; Julie Hudman, Henry J. Kaiser
Family Foundation Commission on Medicaid and the Uninsured; Marian
James, Agency for Healthcare Research and Quality; Linda Johnston Lloyd,
Health Resources and Services Administration; Lloyd J. Kolbe, Centers for
Disease Control; Karen Lechter, Center for Drug Evaluation and Research,
U.S. Food and Drug Administration; Estela Marin, Louisiana State Univer-
sity Health Sciences Center; Ed Martinez, National Association of Public
Hospitals and Health Systems; Frank M. McClellan, Temple University
James E. Beasley School of Law; Linda Morse, New Jersey Office of Aca-
demic and Professional Standards; Francisco Para, Latino Health Access; L.
Gregory Pawlson, National Committee for Quality Assurance; Michael
Pignone, University of North Carolina at Chapel Hill; Francis Prado, Latino
Health Access; Sara Rosenbaum, George Washington University; Marisa
Scala, Center for Medicare Education, American Association of Homes and
Services for the Aging; Lauren Schwartz, New York City Poison Control
Center; Joanne Schwartzberg, American Medical Association; Tetine
Sentell, University of California at Berkeley; Judy A. Shea, University of
Pennsylvania School of Medicine; Susan M. Shinagawa, National Asian-
American and Pacific Islander Cancer Survivors and Advocacy Network;
Colleen Sonosky, George Washington University; Anthony Tirone, Joint
Commission on Accreditation of Healthcare Organizations; Tina Tucker,
American Foundation for the Blind; and Marcia Zorn, National Library of
Medicine.
Special thanks to K. Vish Viswanath and Patrick Weld of the Division
of Cancer Control and Population Sciences of the National Cancer Insti-
tute, Scott Ratzan of Johnson and Johnson, and to Barbara DeBuono and
Joel Rosenquist of the Pfizer Pharmaceutical Group, for extra effort and
repeated attention to the ongoing information needs and support of the
study. The committee appreciates the efforts of Terry C. Pellmar for her
dedication, effort, and commitment to moving this report from concept to
reality in her role as Director of the Board on Neuroscience and Behavioral
Health.
This report was made possible by the generous support of the American
Academy of Family Physicians Foundation, California HealthCare Founda-
tion, Commonwealth Fund, W.K. Kellogg Foundation, MetLife Founda-
tion, National Cancer Institute, Pfizer Corporation, and the Robert Wood
Johnson Foundation.

Foreword
C
lear communication is critical to successful health care. Patients
convey their symptoms and medical history to caregivers; health
professionals issue orders, results, and recommendations to one
another; and doctors, nurses, pharmacists, and others provide information
and instructions to patients. Health professionals are trained to observe
their patients keenly and to elicit a revealing history. Considerable effort
and money are expended to automate reporting of test results and physician
order entry so as to speed availability of clinical information and to reduce
errors. However, comparatively little attention has been devoted to en-
abling patients to comprehend their condition and treatment, to make the
best decisions for their care, and to take the right medications at the right
time in the intended dose. As this report makes clear, health literacy—
enabling patients to understand and to act in their own interest—remains a
neglected, final pathway to high-quality health care.
Tens of millions of U.S. adults are unable to read complex texts, includ-
ing many health-related materials. Arcane language and jargon that become
second nature to doctors and nurses are inscrutable to many patients. Adults
who have a problem understanding written materials are often ashamed
and devise methods to mask their difficulty. They may be reluctant to ask
questions for fear of being perceived as ignorant. If health professionals
were able to take the time to ask their patients to explain exactly what they
understand about their diagnoses, instructions, and bottle labels, the care-
givers would find many gaps in knowledge, difficulties in understanding,
and misinterpretations. These problems are exacerbated by language and
xi

xii FOREWORD
cultural variation in our multicultural society, by technological complexity

in health care, and by intricate administrative documents and requirements.
The Committee on Health Literacy here documents the problem and
describes its origins, consequences, and solutions. The committee echoes
the call of the Surgeon General and other health leaders on the import of
health literacy, and it elaborates the cross-cutting priority for health literacy
identified in the recent Institute of Medicine report on Priority Areas for
National Action in Quality Improvement. Most importantly, the current
report lays out a comprehensive strategy to improve health literacy in Amer-
ica. While this will be neither easy nor completed quickly, individuals,
educators, community groups, health professionals, medical institutions,
industry, and government agencies can all contribute, and this report tells
how.
Health Literacy: A Prescription to End Confusion is a landmark report
on an underappreciated challenge. I am grateful to the committee and its
staff for their work and hope that their report receives the audience, atten-
tion, and action it deserves.
Harvey V. Fineberg, M.D., Ph.D.

President
Institute of Medicine

Preface
M
y understanding of the issues in health literacy was limited prior
to taking on the role of Chair of this committee. From my
expertise in defining and measuring population health and its
determinants, I appreciated the importance of the social determinants of
health. I had speculated about the role of health literacy as one pathway by
which education might exert an independent effect on health outcomes. But
until this rich and intense interaction with my colleagues from diverse fields
such as literacy, biology, health communication, anthropology, epidemiol-
ogy, medicine, nursing, and health policy, combined with poignant testi-
mony from those affected and other experts, I had no idea of the impor-
tance and complexity of this topic.
I believe that what the United States puts into practice in medicine and
health is much less than what is known. Only now do I know how pro-
foundly the gap between knowledge and practice is widened by limited
health literacy. Only now do I know why some refer to this as a “silent
epidemic”—the lack of understanding by most professionals and policy
makers of its extent and effect, and the individual shame associated with it
that keeps it even more silent and hidden.
I hope that this report will produce several outcomes:
• It will become widely appreciated that 90 million adults with lim-

ited health literacy cannot fully benefit from much that the health and
health-care system have to offer.
• It will become widely understood that efforts to improve quality, to
xiii

xiv PREFACE
reduce costs, and to reduce disparities cannot succeed without simulta-

neous improvements in health literacy.
• It will become widely understood that health literacy is more than
reading, but includes writing, numeracy, listening, speaking, and concep-
tual knowledge.
• It will be accepted that improving individual health literacy re-
quires great effort from the public health and health-care systems, the
education system, and society overall.
Chairing this committee was such a privilege and a challenge. We each

struggled to overcome the limitations of our own knowledge and assump-
tions. We could not have completed this work without the many hours
devoted by committee members, those providing testimony, and Institute of
Medicine staff, and the financial support of our sponsors. As one firmly
committed to the translation of research into policy and practice, I hope
this report, containing the results of our efforts, will identify substantial
new resources, not only for the research needed to establish causal relation-
ships and evaluate effective interventions, but also to expand the many
promising interventions identified here. The significance of the problem is
too great to wait for complete understanding before we act.
David A. Kindig, M.D., Ph.D.

Chair

Contents
EXECUTIVE SUMMARY 1
1 INTRODUCTION 19
Social and Economic Factors and Health, 20
Living in a Society with High Literacy Demands, 21
Health Literacy as a Public Concern, 25
Charge to the Committee, 26
Scope of the Report, 27
References, 29
2 WHAT IS HEALTH LITERACY? 31

Definition of Health Literacy, 31
Definition of Literacy, 37
Literacy in Health Contexts, 41
Measures Used in Health Literacy Research, 43
Needs and Opportunities, 51
References, 55
3 THE EXTENT AND ASSOCIATIONS OF LIMITED

HEALTH LITERACY 59
Literacy in America, 60
The Epidemiology of Limited Health Literacy, 65
The Associations of Limited Health Literacy, 81
References, 103
xv

xvi CONTENTS
4 CULTURE AND SOCIETY 108

Traditional Culture, 110
Mass Culture, 119
Opportunities to Improve Health Literacy, 126
References, 137
5 EDUCATIONAL SYSTEMS 142

The K-12 and University Education Systems, 143
The Adult Education System, 154
Education for Health Professionals, 157
References, 162
6 HEALTH SYSTEMS 167

The Context of Health Systems, 168
Opportunities in Health Systems, 201
References, 229
7 VISION FOR A HEALTH-LITERATE AMERICA 240

References, 242
APPENDIXES
A Data Sources and Methods 243

B Commissioned Papers
The Relationship Between Health Literacy and Medical Costs 256
David H. Howard
Improving Chronic Disease Care for Populations with Limited
Health Literacy 267
Dean Schillinger
Outside the Clinician-Patient Relationship: A Call to Action for
Health Literacy 285
Barry D. Weiss
C Sample Material from Selected Assessments of Literacy and
Health Literacy 301
Rapid Estimate of Adult Literacy in Medicine, 302
Excerpts from the Test of Functional Health Literacy
in Adults, 304
Excerpts from the National Adult Literacy Survey, 308
D Committee and Staff Biographies 323
INDEX 331

Tables, Figures, and Boxes
TABLES
2-1 Examples of Skills Needed for Health, 42
3-1 Percentage of Adult Population Groups with Literacy Skills at

NALS Levels 1, 2, or 3–4, 64
3-2 The Epidemiology of Health Literacy Skills Among Various
Populations, 70
3-3 Health-Related Associations of Health Literacy Skills, 84
4-1 Examples of Published Studies of Community-Based

Interventions, 128
6-1 Examples of Informed Consent Text Provided by Institutional

Review Boards at U.S. Medical Schools, 188
6-2 Frequency of Doing Health Literacy-Related Activities, 203
6-3 Samples of Published Studies of Interventions in Health-Care
Settings, 206
A-1 Summary of Respondents and Non-Respondents to Survey, 252
B-1 Representativeness of the Study Sample, 257

B-2 Characteristics of the Study Sample, 259
B-3 Predicted Health-Care Spending, 262
xvii

xviii TABLES, FIGURES, AND BOXES
B-4 In-Sample Prediction of Health Literacy and Total Costs, 263

B-5 How Organizations and Systems Might Act to Improve America’s
Health Literacy, 286
B-6 National Totals for Enrollees and Cost of Hospitalization and
Physician Service Health Plans for the Private Sector, United States,
2000, 291
B-7 Percentage of Adult Population Groups with Literacy Skills at NALS
Levels 1 or 2, 294
C-1 REALM, 302

C-2 Scores and grade equivalents for the REALM, 303
FIGURES
ES-1 Potential points for intervention in the health literacy
framework, 5
2-1 Health literacy framework, 33

2-2 Potential points for intervention in the health literacy
framework, 34
2-3 Components of literacy, 38
3-1 Mock-up presciption medication instructions in Bahasa Malaysia,

the written language of Malaysia, 60
6-1 The concentric ecology of organizations in the health-care

sector, 169
6-2 Difference between actual readability and target readability of
informed consent documents, 189
6-3 National Institutes of Health grant funding over the 1997–2002
period, 196
6-4 Examples of pictograms for patient education, 215
A-1 Response to web-based survey, 251
B-1 Model for improvement of chronic illness care, 269

B-2 Improving chronic disease care: a framework based on
health literacy and related research, 271
B-3 Number of Medicare enrollees, 287
B-4 Federal spending for Medicare, 288
B-5 Predicted Medicare expenditures, 289

TABLES, FIGURES, AND BOXES xix
C-1 Prompt 1 for TOFHLA, 304

C-2 Prompt 10 for TOFHLA, 305
C-3 Article “Swimmer completes Manhattan marathon” used in
NALS, 309
C-4 Discrimination article used in NALS, 311
C-5 Korean jet article used in NALS, 313
C-6 Job application used in NALS, 314
C-7 Wage and tax statement used in NALS, 315
C-8 Sales graph used in NALS, 316
C-9 Energy chart used in NALS, 317
C-10 Bus schedule used in NALS, 318
C-11 Bank deposit slip used in NALS, 320
C-12 Peanut butter label used in NALS, 321
C-13 Home equity loan advertisement used in NALS, 322
BOXES
4-1 Sources of Health Information Reported in a Gallup Poll, 121
4-2 Selected Findings from Sex Matters, 122
4-3 Excerpt from the Introduction to “Language Access: Helping
Non-English Speakers Navigate Health and Human Services”, 135
5-1 The National Health Education Standards, 144
6-1 Rules for Redesigning Health-Care Processes, 178

6-2 State Medicaid Managed Care Contracts, 200
6-3 Example of a Consent Form for Participation in Smoking
Cessation Study, 216
6-4 Examples of Ongoing Approaches Using Technology-Based
Communication Techniques, 218
6-5 Chronic Disease Management Program, 222
6-6 Description of Project Toolbox, 223
6-7 Comments from Respondents to Survey, 227
A-1 First Workshop Hosted by the Committee on Health

Literacy, 246
A-2 Second Workshop Hosted by the Committee on
Health Literacy, 248
A-3 Third Workshop Hosted by the Committee on Health
Literacy, 249


Executive Summary
Understanding is a two-way street. —Eleanor Roosevelt
ABSTRACT
I have a very good doctor. He takes the time to explain things and break it
down to me. Sometimes, though, I do get stuff that can be hard—like when
I first came home from the hospital and I had all these forms and things I had
to read. Some words I come across I just can’t quite understand (National
Center for the Study of Adult Learning and Literacy, 2003).1
Nearly half of all American adults—90 million people—have

difficulty understanding and acting upon health information. The
examples below were selected from the many pieces of complex
consumer health information used in America.
• From a research consent form: “A comparison of the effec-

tiveness of educational media in combination with a counseling
method on smoking habits is being examined.” (Doak et al., 1996)
1All vignettes in shaded text in this report represent actual stories or materials. Names were
omitted in most cases to protect the privacy of the author, and stories may have been edited
for brevity and clarity. If not otherwise attributed, vignettes were drawn from the experiences
of members of the committee.

2 HEALTH LITERACY
• From a consumer privacy notice: “Examples of such man-

datory disclosures include notifying state or local health authorities
regarding particular communicable diseases.”
• From a patient information sheet: “Therefore, patients
should be monitored for extraocular CMV infections and retinitis
in the opposite eye, if only one infected eye is being treated.”
Forty million Americans cannot read complex texts like these

at all, and 90 million have difficulty understanding complex texts.
Yet a great deal of health information, from insurance forms to
advertising, contains complex text. Even people with strong lit-
eracy skills may have trouble obtaining, understanding, and using
health information: a surgeon may have trouble helping a family
member with Medicare forms, a science teacher may not under-
stand information sent by a doctor about a brain function test, and
an accountant may not know when to get a mammogram.
This report defines health literacy as “the degree to which
individuals have the capacity to obtain, process, and understand
basic health information and services needed to make appropriate
health decisions” (Ratzan and Parker, 2000). However, health lit-
eracy goes beyond the individual obtaining information. Health
literacy emerges when the expectations, preferences, and skills of
individuals seeking health information and services meet the expec-
tations, preferences, and skills of those providing information and
services. Health literacy arises from a convergence of education,
health services, and social and cultural factors. Although causal
relationships between limited health literacy and health outcomes
are not yet established, cumulative and consistent findings suggest
such a causal connection.
Approaches to health literacy bring together research and prac-
tice from diverse fields. This report examines the body of knowl-
edge in this emerging field, and recommends actions to promote a
health-literate society. Increasing knowledge, awareness, and re-
sponsiveness to health literacy among health services providers as
well as in the community would reduce problems of limited health
literacy. This report identifies key roles for the Department of
Health and Human Services as well as other public and private
sector organizations to foster research, guide policy development,
and stimulate the development of health literacy knowledge, mea-
sures, and approaches. These organizations have a unique and criti-
cal opportunity to ensure that health literacy is recognized as an
essential component of high-quality health services and health com-
munication.

EXECUTIVE SUMMARY 3
INTRODUCTION
A two-year-old is diagnosed with an inner ear infection and prescribed an

antibiotic. Her mother understands that her daughter should take the pre-
scribed medication twice a day. After carefully studying the label on the
bottle and deciding that it doesn’t tell how to take the medicine, she fills a
teaspoon and pours the antibiotic into her daughter’s painful ear (Parker et
al., 2003).
M
odern health systems make complex demands on the health con-
sumer. As self-management of health care increases, individuals
are asked to assume new roles in seeking information, under-
standing rights and responsibilities, and making health decisions for them-
selves and others. Underlying these demands are assumptions about people’s
knowledge and skills.
National and international assessments of adults’ ability to use written
information suggest that these assumptions may be faulty. Current evidence
reveals a mismatch between people’s skills and the demands of health sys-
tems (Rudd et al., 2000a). Many people who deal effectively with other
aspects of their lives may find health information difficult to obtain, under-
stand, or use. While farmers may be able to use fertilizers effectively, they
may not understand the safety information provided with the fertilizer.
Chefs may create excellent dishes, but may not know how to create a
healthy diet. Indeed, health literacy can be a hidden problem—because it is
often not recognized by policy makers and health care providers, and be-
cause people with low literacy skills or who are confused about health care
may be ashamed to speak up about problems they encounter with the
increasingly complex health system (Baker et al., 1996; Parikh et al., 1996).
Without improvements in health literacy, the promise of scientific advances
for improving health outcomes will be diminished.
The Institute of Medicine (IOM) convened the Committee on Health
Literacy, composed of experts from a wide range of academic disciplines
and backgrounds, to assess the problem of limited health literacy and to
consider the next steps in this field. The committee addressed the following
charge:
1. Define the scope of the problem of health literacy. The intent is to

clarify the root problems that underlie health illiteracy. This would include
identifying the affected populations and estimating the costs for society.
Develop a set of basic indicators of health literacy to allow assessment of
the extent of the problem at the individual, community, and national levels.

4 HEALTH LITERACY
2. Identify the obstacles to a creating a health-literate public. These

are likely to include the complexity of the health care system, the many
and often contradictory health messages, rapidly advancing technologies,
limits within public education to promote literacy of adults as well as
children, etc.
3. Assess the approaches that have been attempted to increase health
literacy both in the United States and abroad. Identify the gaps in research
and programs that need to be addressed. The focus should be on public
health interventions attempting to increase health literacy of the public
rather than on improving health provider/primary care interactions.
4. Identify goals for health literacy efforts and suggest approaches to
overcome the obstacles to health literacy in order to reach these goals.
These might include research or policy initiatives, interventions, or collabo-
rations that would promote health literacy.
WHAT IS HEALTH LITERACY?

In this report, the committee accepted the definition of health literacy
presented by the National Library of Medicine (Selden et al., 2000) and
used in Healthy People 2010 (HHS, 2000):
The degree to which individuals have the capacity to obtain, process, and
understand basic health information and services needed to make appro-
priate health decisions (Ratzan and Parker, 2000).
Health literacy is a shared function of social and individual factors.
Individuals’ health literacy skills and capacities are mediated by their edu-
cation, culture, and language. Equally important are the communication
and assessment skills of the people with whom individuals interact regard-
ing health, as well as the ability of the media, the marketplace, and govern-
ment agencies to provide health information in a manner appropriate to the
audience.
The committee developed a framework for health literacy which identi-
fies three major areas of potential intervention and forms the organiza-
tional principle of this report (see Figure ES-1). This framework illustrates
the potential influence on health literacy as individuals interact with educa-
tional systems, health systems, and cultural and social factors, and suggests
that these factors may ultimately contribute to health outcomes and costs.
The proposed framework is a model, because available research supports
only limited conclusions about causality. However, the cumulative effect of
a body of consistent evidence suggests that causal relationships may exist
between health literacy and health outcomes. Research is needed to estab-
lish the nature of the causal relationships between and among the various
factors portrayed in the framework.

EXECUTIVE SUMMARY 5
Potential Intervention Points

2
Health
System Health
1 Outcomes
and Costs
Culture
and Health
Literacy
Society
Education
System
3
FIGURE ES-1 Potential points for intervention in the health literacy framework.
The committee reviewed the strengths and limitations of currently avail-

able measures of literacy and health literacy. Health literacy involves a
range of social and individual factors, and includes cultural and conceptual
knowledge, listening, speaking, arithmetical, writing, and reading skills.
However, most of the tools currently available to measure health literacy
primarily measure reading skills, and do not include other critical skills.
Furthermore, adults’ reading abilities are often estimated with a “grade
level” measure, an estimate that is imprecise at best. Advancement of the
field of health literacy requires the development of new measures which can
be used to establish baseline levels and monitor change over time.
Finding 2-1 Literature from a variety of disciplines is consistent in

finding that there is strong support for the committee’s conclusion that
health literacy, as defined in this report, is based on the interaction of
individuals’ skills with health contexts, the health-care system, the educa-
tion system, and broad social and cultural factors at home, at work, and in
the community. The committee concurs that responsibility for health
literacy improvement must be shared by these various sectors. The com-
mittee notes that the health system does carry significant but not sole
opportunity and responsibility to improve health literacy.
Finding 2-2 The links between education and health outcomes are
strongly established. The committee concludes that health literacy may be

6 HEALTH LITERACY
one pathway explaining the well-established link between education and

health, and warrants further exploration.
Finding 2-3 Health literacy, as defined in this report, includes a vari-

ety of components beyond reading and writing, including numeracy, listen-
ing, speaking, and relies on cultural and conceptual knowledge.
Finding 2-4 While health literacy measures in current use have spurred
research initiatives and yield valuable insights, they are indicators of read-
ing skills (word recognition or reading comprehension and numeracy),
rather than measures of the full range of skills needed for health literacy
(cultural and conceptual knowledge, listening, speaking, numeracy, writ-
ing, and reading). Current assessment tools and research findings cannot
differentiate among (a) reading ability, (b) lack of background knowledge
in health-related domains, such as biology, (c) lack of familiarity with
language and types of materials, or (d) cultural differences in approaches to
health and health care. In addition, no current measures of health literacy
include oral communication skills or writing skills and none measure the
health literacy demands on individuals within different health contexts.
THE EXTENT AND ASSOCIATIONS OF

LIMITED HEALTH LITERACY
Studies of health literacy or of literacy in health contexts suggest that
limited health literacy skills, as measured by current assessment tools, are
common, with significant variations in prevalence depending on the popu-
lation sampled (see Chapter 3). People of all literacy levels may be able to
manage texts that they frequently encounter and use for everyday activities,
but will often face problems with difficult and confusing types of text
(Kirsch et al., 1993).
Findings from the National Adult Literacy Survey (NALS) and Interna-
tional Adult Literacy Surveys (IALS) indicate that a large percentage of
adults lack the literacy skills needed to meet the demands of twenty-first
century society. More than 47 percent, or 90 million, of U.S. adults have
difficulty locating, matching, and integrating information in written texts
with accuracy and consistency. Of the 90 million with limited literacy skills,
about 40 million can perform simple and routine tasks using uncomplicated
materials. An additional 50 million adults can locate information in moder-
ately complicated texts, make inferences using print materials, and inte-
grate easily identifiable pieces of information. However, they find it diffi-
cult to perform these tasks when complicated by distracting information
and complex texts (Kirsch, 2001; Kirsch et al., 1993).
These findings have serious implications for the health sector. Over 300

EXECUTIVE SUMMARY 7
studies, conducted over three decades and assessing various health-related

materials, such as informed consent forms and medication package inserts,
have found that a mismatch exists between the reading levels of the materi-
als and the reading skills of the intended audience. In fact, most of the
assessed materials exceed the reading skills of the average high school
graduate (Rudd et al., 2000a).
Studies suggest that while individuals with limited health literacy come
from many walks of life, the problem of limited health literacy is often
greater among older adults, people with limited education, and those with
limited English proficiency (e.g., Beers et al., 2003; Gazmararian et al.,
1999; Williams et al., 1995). For individuals whose native language is not
English, issues of health literacy are compounded by issues of basic commu-
nication and the specialized vocabulary used to convey health information.
Associations with Health Knowledge,

Behavior, and Outcomes
Research linking limited health literacy as it is currently measured to
health knowledge, health behaviors, and health outcomes is accumulating.
Patients with limited health literacy and chronic illness have less knowledge
of illness management than those with higher health literacy (Kalichman et
al., 2000; Schillinger et al., 2002; Williams et al., 1998a, b). Compared to
those with adequate health literacy, patients with limited health literacy
have decreased ability to share in decision-making about prostate cancer
treatment (Kim et al., 2001), lower adherence to anticoagulation therapy
(Lasater, 2003; Win and Schillinger, 2003), higher likelihood of poor glyce-
mic control (Schillinger et al., 2002), and lower self-reported health status
(Arnold et al., 2001; Baker et al., 2002; Kalichman and Rompa, 2000;
Kalichman et al., 2000; Williams et al., 1998a, b).
Financial Associations of Limited Health Literacy

The limited amount of data available suggests that there is an associa-
tion between health literacy, health-care utilization, and health-care costs.
Baker and others (2002) found that public hospital patients with limited
health literacy had higher rates of hospitalization than those with adequate
health literacy. This increased hospitalization rate may be associated with
greater resource use. Another analysis (Friedland, 1998) concluded that the
additional health expenditure attributable to inadequate reading skills (as
identified by the NALS) in 1996 was $29 billion. This estimate would
increase to $69 billion if as few as half the individuals with marginal
reading skills were also not health literate. Weiss and Palmer (2004) re-
ported on a direct measure of cost in a small sample of Medicaid patients in

8 HEALTH LITERACY
Arizona. Patients with reading levels at or below third grade had mean
Medicaid charges $7,500 higher than those who read above the third grade
level.
For this report, David Howard examined the expenditure data col-
lected in association with the Baker and colleagues (2002) utilization study
(see Appendix B). He found that predicted inpatient spending for a patient
with inadequate health literacy was $993 higher than that of a patient with
adequate reading skills. A difference of $450 remained after controlling
for health status, although the causality of the associations between health
status and health-care cost could not be determined. In both analyses,
higher emergency care costs were incurred by individuals with limited
health literacy compared to those with marginal or adequate health lit-
eracy as measured by the Test of Functional Health Literacy in Adults
(TOFHLA), while pharmacy expenses were similar and outpatient expen-
ditures lower.
Although a robust estimate for the effect of limited health literacy on
health expenditures is lacking, the magnitudes suggested by the few studies
that are available underscore the importance of addressing limited health
literacy from a financial perspective.
Finding 3-1 About 90 million adults, an estimate based on the 1992

NALS, have literacy skills that test below high school level (NALS Level 1
and 2). Of these, about 40–44 million (NALS Level 1) have difficulty
finding information in unfamiliar or complex texts such as newspaper ar-
ticles, editorials, medicine labels, forms, or charts. Because the medical and
public health literature indicates that health materials are complex and
often far above high school level, the committee notes that approximately
90 million adults may lack the needed literacy skills to effectively use the
U.S. health system. The majority of these adults are native-born English
speakers. Literacy levels are lower among the elderly, those who have lower
educational levels, those who are poor, minority populations, and groups
with limited English proficiency such as recent immigrants.
Finding 3-2 On the basis of limited studies, public testimony, and

committee members’ experience, the committee concludes that the shame
and stigma associated with limited literacy skills are major barriers to
improving health literacy.
Finding 3-3 Adults with limited health literacy, as measured by read-

ing and numeracy skills, have less knowledge of disease management and of
health-promoting behaviors, report poorer health status, and are less likely
to use preventive services.

EXECUTIVE SUMMARY 9
Finding 3-4 Two recent studies demonstrate a higher rate of hospital-

ization and use of emergency services among patients with limited literacy.
This higher utilization has been associated with higher health-care costs.
THE CONTEXTS OF HEALTH LITERACY AND

OPPORTUNITIES FOR INTERVENTION
Culture and Society
The ho’ola said Mom should confess to me and before God Jehovah. She
did. She asked me to forgive her and I did. I wasn’t angry. . . . And later
Mom’s sickness left her. Of course, she still had diabetes, but the rest—being
so confused and miserable—all that left her (Shook, 1985: 109).
Culture is the shared ideas, meanings, and values that are acquired by
individuals as members of a society. Culture is socially learned, continually
evolves, and often influences us unconsciously. We learn culture through
interactions with others, as well as through the tangible products of culture
such as books and television (IOM, 2002). Culture gives significance to
health information and messages, and can shape perceptions and defini-
tions of health and illness, preferences, language and cultural barriers, care
process barriers, and stereotypes. These culturally influenced perceptions,
definitions, and barriers can affect how people interact with the health care
system and help to determine the adequacy of health literacy skills in differ-
ent settings.
The fluid nature of culture means that health-care encounters are rich
with differences that are continuously evolving. Differing cultural and
educational backgrounds between patients and providers, as well as be-
tween those who create health information and those who use it, may
contribute to problems in health literacy. Culture, cultural processes, and
cross-cultural interventions have been discussed in depth in several recent
IOM reports and represent possible nexuses of culture and health literacy
(IOM, 2002, 2003a).
It is important to understand how people obtain and use health infor-
mation in order to understand the potential impact of health literacy. Infor-
mation about health is produced by many sources, including the govern-
ment and the food and drug industries, and is distributed by the popular
media. Commercial and social marketing of health information, products,
and services is a multibillion dollar industry. People are frequently and
repeatedly exposed to quick, often contradictory bits of information. This

10 HEALTH LITERACY
inundation with information has increased as the Internet has become an

increasingly important source of health information. Socioeconomic status,
education level, and primary language all affect whether consumers will
seek out health information, where they will look for the information, what
type of information they prefer, and how they will interpret that informa-
tion. Limited health literacy decreases the likelihood that health-related
information will be accessible to all (Houston and Allison, 2002).
Finding 4-1 Culture gives meaning to health communication. Health

literacy must be understood and addressed in the context of culture and
language.
Finding 4-2 More than 300 studies indicate that health-related mate-
rials far exceed the average reading ability of U.S. adults.
Finding 4-3 Competing sources of health information (including the

national media, the Internet, product marketing, health education, and
consumer protection) intensify the need for improved health literacy.
Finding 4-4 Health literacy efforts have not yet fully benefited from
research findings in social and commercial marketing.
The Educational System

Adult education is an important resource for individuals with limited
literacy or limited English proficiency. A major source of support for Ameri-
can adult education programs in literacy is the U.S. adult basic education
and literacy (ABEL) system. ABEL programs provide classes in topics that
support health literacy including basic literacy and math skills, English
language, and high school equivalence, and predominantly serve students
with literacy and math skills in NALS Levels 1, 2, or the low end of NALS
Level 3. Sadly, these programs serve far fewer than the millions of Ameri-
cans who could benefit.
Both childhood literacy education and childhood health education can
provide a basis for health literacy in adulthood. Although most elementary,
middle, and high schools require students to take health education, the
sequence of coursework is not coordinated. The percentage of schools that
require health education increases from 33 percent in kindergarten to 44
percent in grade 5, but then falls to 10 percent in grade 9, and 2 percent in
grade 12. The absence of a coordinated health education program across
grade levels may impede student learning of needed health literacy skills.
Furthermore, only 9.6 percent of health education classes have a teacher

EXECUTIVE SUMMARY 11
who majored in health education or in combined health and physical edu-

cation (Kann et al., 2001).
In 1995, the Joint Committee on National Health Standards published
the National Health Education Standards with the subtitle Achieving Health
Literacy. These standards describe the knowledge and skills essential for
health literacy, and detail what students should know and be able to do in
health education by the end of grades 4, 8, and 11. They provide a frame-
work for curricula development and student assessment. Unfortunately,
these standards have not been widely met.
Finding 5-1 Significant obstacles and barriers to successful health lit-

eracy education exist in K-12 education programs.
Finding 5-2 Opportunities for measuring literacy skill levels required

for health knowledge and skills, and for the implementation of programs to
increase learner’s skill levels, currently exist in adult education programs
and provide promising models for expanding programs. Studies indicate a
desire on the part of adult learners and adult education programs to form
partnerships with health communities.
Finding 5-3 Health professionals and staff have limited education,

training, continuing education, and practice opportunities to develop skills
for improving health literacy.
Health Systems
Health systems in the United States are complex and often confusing.
Their complexity derives from the nature of health care and public health
itself, the mix of public and private financing, and the variations across
states and between types of delivery settings. An adult’s ability to navigate
these systems may reflect this systemic complexity in addition to individual
skill levels. Even highly skilled individuals may find the systems too compli-
cated to understand, especially when these individuals are made more vul-
nerable by poor health. Directions, signs, and official documents, including
informed consent forms, social services forms, public health information,
medical instructions, and health education materials, often use jargon and
technical language that make them unnecessarily difficult to use (Rudd et
al., 2000b). In addition, cultural differences may affect perceptions of
health, illness, prevention, and health care. Lack of mutual understanding
of health, illness and treatments, and risks and benefits has implications for
behavior for both providers and consumers, and legal implications for
providers and health systems. Imagine having to face this complexity if you

12 HEALTH LITERACY
are one of the 90 million American adults who lack the functional literacy
skills in English to use the U.S. health care system.2
Health literacy permeates all areas of the provider–consumer informa-
tion exchange, and provides a common pathway for the successful transfer
of information. A number of emerging areas are likely to increase the
burden of limited health literacy on those entering and using the health-care
system. These include demands inherent in chronic disease management,
increased use of new technologies, decreased time for patient/provider dis-
cussions, and legal and regulatory requirements.
Many different interventions and approaches that may hold promise
for addressing limited health literacy are being attempted across health-care
systems, professional organizations, federal and state agencies, educational
institutions, and community and advocacy groups across the United States
and in other countries. Those profiled in the report are indicators of the
creativity and promise for future improvements in countering the effects of
limited health literacy. However, few of these approaches have been for-
mally evaluated, and most are fragmented single approaches rather than
part of a systematic approach to health literacy. In order for progress to be
made, many more systematic demonstrations must be funded and rigor-
ously evaluated.
Finding 6-1 Demands for reading, writing, and numeracy skills are
intensified due to health-care systems’ complexities, advancements in scien-
tific discoveries, and new technologies. These demands exceed the health-
literacy skills of most adults in the United States.
Finding 6-2 Health literacy is fundamental to quality care, and relates

to three of the six aims of quality improvement described in the IOM
Quality Chasm Report: safety, patient-centered care, and equitable treat-
ment. Self-management and health literacy have been identified by IOM as
cross-cutting priorities for health-care quality and disease prevention.
Finding 6-3 The readability levels of informed consent documents

(for research and clinical practice) exceed the documented average reading
levels of the majority of adults in the United States. This has important
ethical and legal implications that have not been fully explored.
VISION FOR A HEALTH-LITERATE AMERICA

The evidence and judgment presented in this report indicate that heath
literacy is important to improving the health of individuals and popula-
2See Finding 3-1.

tions. This is supported by the conclusions and statements of others. Health

literacy was one of two cross-cutting factors that affect health care identi-
fied by the IOM in its recent report Priority Areas for National Action in
Quality Improvement (IOM, 2003b). The Surgeon General recently stated
that “health literacy can save lives, save money, and improve the health and
well being of millions of Americans . . . health literacy is the currency of
success for everything I am doing as Surgeon General” (Carmona, 2003).
More needs to be known about the causal pathways between education
and health, the role of literacy, and the discrete contribution of health
literacy to health. With this knowledge we will be able to understand which
interventions and approaches are the most appropriate and effective. This
Committee believes that a health-literate America is an achievable goal. We
envision a society within which people have the skills they need to obtain,
interpret, and use health information appropriately and in meaningful ways.
We envision a society in which a variety of health systems structures and
institutions take responsibility for providing clear communication and ad-
equate support to facilitate health-promoting actions based on understand-
ing. We believe a health-literate America would be a society in which:
• Everyone has the opportunity to improve their health literacy.

• Everyone has the opportunity to use reliable, understandable infor-
mation that could make a difference in their overall well-being, including
everyday behaviors such as how they eat, whether they exercise, and whe-
ther they get checkups.
• Health and science content would be basic parts of K-12 curricula.
• People are able to accurately assess the credibility of health infor-
mation presented by health advocate, commercial, and new media sources.
• There is monitoring and accountability for health literacy policies
and practices.
• Public health alerts, vital to the health of the nation, are presented
in everyday terms so that people can take needed action.
• The cultural contexts of diverse peoples, including those from vari-
ous cultural groups and non-English-speaking peoples, are integrated in to
all health information.
• Health practitioners communicate clearly during all interactions
with their patients, using everyday vocabulary.
• There is ample time for discussions between patients and health-
care providers.
• Patients feel free and comfortable to ask questions as part of the
healing relationship.
• Rights and responsibilities in relation to health and health care are
presented or written in clear, everyday terms so that people can take needed
action.

14 HEALTH LITERACY
• Informed consent documents used in health care are developed so

that all people can give or withhold consent based on information they need
and understand.
While achieving this vision is a profound challenge, we believe that

significant progress can and must be made over the coming years, so that
the potential for optimal health can benefit all individuals and populations
in our society.
Recommendation 2-1 The Department of Health and Human Services and oth-
er government and private funders should support research leading to the devel-
opment of causal models explaining the relationships among health literacy, the
education system, the health system, and relevant social and cultural systems.
Recommendation 2-2 The Department of Health and Human Services and pub-
lic and private funders should support the development, testing, and use of cultur-
ally appropriate new measures of health literacy. Such measures should be devel-
oped for large ongoing population surveys, such as the National Assessment of
Adult Literacy Survey, Medical Expenditure Panel Survey, and Behavioral Risk
Factor Surveillance System, and the Medicare Beneficiaries Survey, as well as for
institutional accreditation and quality assessment activities such as those carried
out by the Joint Commission on Accreditation of Healthcare Organizations and the
National Committee for Quality Assurance. Initially, the National Institutes of Health
should convene a national consensus conference to initiate the development of
operational measures of health literacy which would include contextual measures.
Recommendation 3-1 Given the compelling evidence noted above, funding for
health literacy research is urgently needed. The Department of Health and Human
Services, especially the National Institutes of Health, Agency for Healthcare Re-
search and Quality, Health Resources and Services Administration, the Centers
for Disease Control and Prevention, Department of Defense, Veterans Administra-
tion, and other public and private funding agencies should support multidisciplinary
research on the extent, associations, and consequences of limited health literacy,
including studies on health service utilization and expenditures.
Recommendation 4-1 Federal agencies responsible for addressing disparities

should support the development of conceptual frameworks on the intersection of
culture and health literacy to direct in-depth theoretical explorations and formulate
the conceptual underpinnings that can guide interventions.
4-1.a The National Institutes of Health should convene a consensus confer-
ence, including stakeholders, to develop methodology for the incorporation of
health literacy improvement into approaches to health disparities.
4-1.b The Office of Minority Health and Agency for Healthcare Research
and Quality should develop measures of the relationships between culture,
language, cultural competency, and health literacy to be used in studies of
the relationship between health literacy and health outcomes.

Recommendation 4-2 The Agency for Healthcare Research and Quality, the
Centers for Disease Control and Prevention, the Indian Health Service, the Health
Resources and Services Administration, and the Substance Abuse and Mental
Health Services Administration should develop and test approaches to improve
health communication that foster healing relationships across culturally diverse
populations. This includes investigations that explore the effect of existing and
innovative communication approaches on health behaviors, and studies that ex-
amine the impact of participatory action and empowerment research strategies for
effective penetration of health information at the community level.
Recommendation 5-1 Accreditation requirements for all public and private edu-
cational institutions should require the implementation of the National Health Edu-
cation Standards.
Recommendation 5-2 Educators should take advantage of the opportunity pro-

vided by existing reading, writing, reading, oral language skills, and mathematics
curricula to incorporate health-related tasks, materials, and examples into existing
lesson plans.
Recommendation 5-3 The Health Resources and Services Administration and

the Centers for Disease Control and Prevention, in collaboration with the Depart-
ment of Education, should fund demonstration projects in each state to attain the
National Health Education Standards and to meet basic literacy requirements as
they apply to health literacy.
Recommendation 5-4 The Department of Education in association with the De-

partment of Health and Human Services should convene task forces comprised of
appropriate education, health, and public policy experts to delineate specific, fea-
sible, and effective actions relevant agencies could take to improve health literacy
through the nation’s K-12 schools, 2-year and 4-year colleges and universities,
and adult and vocational education.
Recommendation 5-5 The National Science Foundation, the Department of Ed-

ucation, and the National Institute of Child Health and Human Development should
fund research designed to assess the effectiveness of different models of combin-
ing health literacy with basic literacy and instruction. The Interagency Education
Research Initiative, a federal partnership of these three agencies, should lead this
effort to the fullest extent possible.
Recommendation 5-6 Professional schools and professional continuing educa-

tion programs in health and related fields, including medicine, dentistry, pharmacy,
social work, anthropology, nursing, public health, and journalism, should incorpo-
rate health literacy into their curricula and areas of competence.
Recommendation 6-1 Health care systems, including private systems, Medi-

care, Medicaid, the Department of Defense, and the Veterans Administration
should develop and support demonstration programs to establish the most effec-
Continued

16 HEALTH LITERACY
tive approaches to reducing the negative effects of limited health literacy. To ac-
complish this, these organizations should:
• Engage consumers in the development of health communications and in-

fuse insights gained from them into health messages.
• Explore creative approaches to communicate health information using print-
ed and electronic materials and media in appropriate and clear language. Messag-
es must be appropriately translated and interpreted for diverse audiences.
• Establish methods for creating health information content in appropriate and
clear language using relevant translations of health information.
• Include cultural and linguistic competency as an essential measure of qual-
ity of care.
Recommendation 6-2 The Department of Health and Human Services should

fund research to define the needed health literacy tasks and skills for each of the
priority areas for improvement in health care quality. Funding priorities should in-
clude participatory research which engages the intended populations.
Recommendation 6-3 Health iteracy assessment should be a part of health-

care information systems and quality data collection. Public and private accredita-
tion bodies, including Medicare, the National Committee for Quality Assurance,
and the Joint Commission on Accreditation of Healthcare Organizations should
clearly incorporate health literacy into their accreditation standards.
Recommendation 6-4 The Department of Health and Human Services should

take the lead in developing uniform standards for addressing health literacy in
research applications. This includes addressing the appropriateness of research
design and methods and the match among the readability of instruments, the liter-
acy level, and the cultural and linguistic needs of study participants. In order to
achieve meaningful research outcomes in all fields:
• Investigators should involve patients (or subjects) in the research process to

ensure that methods and instrumentation are valid and reliable and in a language
easily understood.
• The National Institutes of Health should collaborate with appropriate federal
agencies and institutional review boards to formulate the policies and criteria to
ensure that appropriate consideration of literacy is an integral part of the approval
of research involving human subjects.
• The National Institutes of Health should take literacy levels into account when
considering informed consent in human subjects research. Institutional Review
Boards should meet existing standards related to the readability of informed con-
sent documents.

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Kirsch IS. 2001. The International Adult Literacy Survey (IALS): Understanding What Was
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Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. 1993. Adult Literacy in America: A First Look
at the Results of the National Adult Literacy Survey (NALS). Washington, DC: National
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[accessed: December 4, 2003].
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nal Medicine. 18(Supplement 1): 278.

Introduction
A two-year-old is diagnosed with an inner ear infection and prescribed an

antibiotic. Her mother understands that her daughter should take the pre-
scribed medication twice a day. After carefully studying the label on the
bottle and deciding that it doesn’t tell how to take the medicine, she fills a
teaspoon and pours the antibiotic into her daughter’s painful ear (Parker et
al., 2003).
H
ealth consumers face numerous challenges as they seek health
information, including the complexity of the health systems, the
rising burden of chronic disease, the need to engage as partners in
their care, and the proliferation of consumer information available from
numerous and diverse sources. Individuals are asked to assume new roles in
seeking information, advocating for their rights and privacy, understanding
responsibilities, measuring and monitoring their own health and that of
their community, and making decisions about insurance and options for
care. Underlying these complex demands are the varying and sometimes
inadequate levels of, first, consumer knowledge and, second, skills for using
and applying a wide range of health information.
In their work, health care educators and providers make assumptions
about an individual’s ability to comprehend health information. However
over 300 studies have shown that health information cannot be understood
by most of the people for whom it was intended, suggesting that the as-
sumptions regarding the recipient’s level of health literacy made by the
19

20 HEALTH LITERACY
creators of this information are often incorrect. Over the past decade,
concerns related to literacy skills and health provided a wake-up call to
many in the health fields. Health literacy, a newly emerging field of inquiry
and practice, focuses on literacy concerns within the context of health. The
committee defines health literacy as “the degree to which individuals have
the capacity to obtain, process, and understand basic health information
and services needed to make appropriate health decisions” (Ratzan and
Parker, 2000), and views health literacy as a shared function of social and
individual factors. This chapter will provide an overview of health literacy
and this report in a broad societal context; please refer to Chapter 2 for an
in-depth discussion of the definition and conceptual basis of health literacy.
SOCIAL AND ECONOMIC FACTORS AND HEALTH

Epidemiologists have been able to document links between socioeco-
nomic status and health, and links between educational attainment and
health. A 1998 report from the U.S. Department of Health and Human
Services offered evidence from accumulated studies that health, morbidity,
and mortality are related to income and education factors (Pamuk et al.,
1998). For example, life expectancy is related to family income. So too are
death rates from cancer and heart disease, incidences of diabetes and hyper-
tension, and use of health services. Similarly, death rates for chronic dis-
ease, communicable diseases, and injuries as reported in 1998 were in-
versely related to education: those with lower education achievement are
more likely to die of a chronic disease than are those with higher education
achievement. In essence, the lower your income or educational achieve-
ment, the worse your health.
Some researchers have suggested that education provides a key to un-
derstanding these relationships. Grossman and Kaestner (1997) asserted
that “Years of formal schooling completed is the most important correlate
of good health.” House and colleagues (1994) noted that “A causal impact
of education on health is highly plausible.” However, research has not yet
fully examined other aspects or measures of education beyond years in
school such as knowledge and skills. Literacy is one set of skills related to
education. National literacy assessments indicate that literacy is a set of
measurable skills (Kirsch, 2001) that includes reading, writing, listening,
speaking, and arithmetical skills. Chapter 3 discusses the research that
exists on the relationship between literacy and health.
Culture and ethnicity also influence health, and Chapter 4 of this report
includes a discussion of their relationship with health literacy. Culture and
ethnicity are often blended into categories of race which may not represent
scientifically sound classifications. As discussed in a recent Institute of Medi-
cine (IOM) report, Speaking of Health (IOM, 2002), race is not a meaning-

INTRODUCTION 21
ful biological classification system for human populations, and even

ethnicity can be interpreted too rigidly. This IOM report drew on current
anthropological thinking to suggest that both individuals and populations
should be assessed in terms of the influences on their lives and cultural
histories, or “experiential identity.” This experiential identity may include
influences from multiple cultures and languages, sometimes within the same
family, but more often from life experiences. People’s knowledge and un-
derstanding of their health, and their health literacy, are based on a com-
posite of these life experiences. In this report, the terms race and ethnicity
will be used in the discussions of population studies.
LIVING IN A SOCIETY WITH HIGH LITERACY DEMANDS

Every day, millions of adults must make decisions and take actions on
issues that protect not only their own well-being, but also that of their
family members and communities. These actions are not confined to tradi-
tional health-care settings such as doctors and dentists’ offices, hospitals,
and clinics. They take place in homes, at work, in schools, and in commu-
nity forums across the country. Health-related activities are part of the
daily life of adults, whether they are sick or well.
At home, parents may have to calculate a child’s weight and age to
determine the correct dosage of an over-the-counter medicine. People are
also expected to follow directions from health-care providers, presented
verbally or in writing, during recovery from an illness or the management
of a chronic disease. At work, employees may need to determine correct
workstation placement or safe use of toxic chemicals. Safety warnings are
posted in the community, and at work, and are discussed in newspapers
and on television. Many health-related decisions are made in the market-
place. When reading nutritional information on food labels, for example,
consumers are expected to understand that calculation of sugar content
must include the sugar listed on the snack food label as well as the fructose
and corn syrup. In the pharmacy, consumers must differentiate between a
cough syrup that is an expectorant and one that is a suppressor.
Examples of language taken from actual product and warning labels
• Topical antiseptic bactericide/viricide for degerming skin and mucus

membranes
• Non-potable water
• Notify appropriate authorities

22 HEALTH LITERACY
In medical care settings, health-care providers expect patients to pro-

vide accurate health histories and descriptions of their symptoms, as well as
listen to and comprehend verbal instructions (Roter et al., 1998).
Sometimes the doctors and pharmacy use the type of words that are some-
times hard. I mean sometimes there’s some word that, it’s there, but you don’t
know what it means. They are using those fine words, those college words,
that are hard for people like me to understand and read (Rudd and DeJong,
2000).
Adults need to meet the demands of bureaucracies and institutions to

access health programs and services. For example, adults are asked to fill
out insurance forms, understand their rights and responsibilities, provide
medical history, and provide informed consent for medical procedures. The
documents required for some of these activities often contain legal and
scientific terms unfamiliar to many individuals.
Signs and directions posted for employees and visitors outside and
within institutions are often inadequate. As Baker and colleagues noted in a
study based on patient focus groups at two public hospitals, many of the
patients did not benefit from signs indicating that the nephrology unit was
straight ahead. The nephrologists, however, most likely knew where to go
(Baker et al., 1996; Rudd, 2002).
An inability to speak English at all or an ability to speak with only
limited proficiency presents additional obstacles to understanding health
information and accessing health care. These obstacles are compounded
when written translations and trained translators are not available (Carras-
quillo et al., 1999; Flores et al., 2003; IOM, 2003a; Sarver and Baker,
2000).
When I started six months ago, it was a new job and it was transporting
patients. So we got a dispatcher. We had to call back to the floor and get the
orders where to take the patients. I went looking for about 30 minutes. The
patient and I were lost (Rudd and DeJong, 2000).
The presentation of health information is often unnecessarily complex.

Findings from three decades of early medical and public health studies
examining the reading level of print materials developed for patient educa-
tion and for procedures and processes in the health-care setting (Rudd et
al., 2000) established that most health materials fall into reading level
ranges requiring high school, college, or graduate degrees. Overall, the

INTRODUCTION 23
literacy demands of health materials exceeded the reading abilities of the

average American adult.
In addition, the language typically used by those working in health and
medicine is filled with scientific jargon. This increases the difficulty for the
average consumer. References are made to biological systems (e.g., endo-
crine) and anatomy (e.g., atrial valve) as well as to groupings of diseases
and disorders (e.g., renal, cardiovascular, neurological, respiratory) that are
not typically used in everyday conversation. Furthermore, they are scientific
terms not typically taught in the K-12 school system. For example, many
people do not know that they have bronchi or where they are located; yet
those with asthma will be presented with the very critical information that
this chronic disease involves inflammation of the bronchi and that a par-
ticular type of medicine helps. A person’s ability to understand health,
medical issues, and directions is related to the clarity of the communication.
After being diagnosed with recurrent aphthous stomatitis involving the epithelium
of the buccal mucosa, Winston did what he thought was necessary.
Which is a funny thing to do for a canker.

SOURCE: Canadian Public Health Association, Plain Language Service. Reprinted
with permission.
Of course, literacy demands differ by setting and by circumstance. The

types of health information a person is exposed to changes as a person’s life
changes. Sociological and anthropological research has documented that
literacy practices are inextricably intertwined and shaped by life circum-
stances (Barton and Hamilton, 1998; Purcell-Gates et al., 2000; Street,

24 HEALTH LITERACY
2001). For example, a woman is more likely to receive information about

hormone replacement therapy after menopause rather than when she is a
teenager. Purcell-Gates documented how literacy demands changed in the
lives of adult education students because of life events such as a new living
situation or a change in a family member’s health. For example, the adults
in this study reported that new health literacy demands arose with the birth
of their children. They were required to fill out health history forms, main-
tain vaccination records, and keep track of their children’s appointments
with health-care workers. They needed to read and understand dosage
instructions on over-the-counter and prescription medications for their in-
fants. They were required to install car seats by following printed direc-
tions. Those with school-aged children needed to read and sign materials
sent home from school related, for example, to lunch programs or field
trips.
Changes in their own or a family member’s health were often reported
as initiating a change in literacy practice. A commonly reported change was
the beginning of, or increase in, reading associated with medicines: print on
medicine bottles, prescriptions, and directions from doctors. Many reported
a need to read the print on food containers for the first time as part of the
vigilance required in managing a chronic illness like diabetes. Following a
health change that necessitated repeated doctor visits, people found and
read medical reference books, and began to use personal calendars and
appointment books (Purcell-Gates et al., 2000).
Demands on an individual’s literacy skills can create a barrier to the use
and understanding of health tools and information. In many ways, literacy
serves as a social determinant of health when a mismatch exists between the
skills of the individual and the literacy skill demands of the health context.
Poor communication, whether it be based on faulty assumptions, inappro-
priate language, incomplete disclosures, or hidden confusion, does a disser-
vice to clients as well as to health-care professionals. When words get in the
way, the communication process fails, leading to confusion, loss of dignity,
and unhealthful outcomes.
Another result of this failure of communication is that limited health
literacy is often undetected, in part because individuals with limited literacy
skills may feel ashamed. People may not be at ease acknowledging reading
difficulties or vocabulary limitations. Consequently, they may feel shame or
mask these difficulties in order to maintain dignity (Baker et al., 1996;
Parikh et al., 1996).
Identifying the extent of limited health literacy is also problematic
because individuals tend not to tell their health-care providers about lit-
eracy problems that they encounter in the increasingly complex health
system, including trouble understanding both printed materials and the
meaning of discussions with providers. Also of concern is the possibility

INTRODUCTION 25
that people may perceive their skills to be adequate when they are not. For
example, data from the 1992 National Adult Literacy Survey (NALS) show
that among those scoring in the lowest level on the prose literacy scale, only
29 percent reported they did not read well and only 34 percent reported
they did not write well. The majority of those performing at this level
perceive their reading and writing skills to be adequate. Among those in the
next highest level the results were even more surprising, as only 3 percent
said they couldn’t read well and 6 percent said they couldn’t write well
(Kirsch et al., 1993; see Chapter 2 for more information on the NALS).
To Err Is Human: Building a Safer Health System is a widely publicized
IOM study on the quality of health care that examined factors to medical
errors (IOM, 2000). One study cited in this report found that 10 percent of
adverse drug events were linked to errors in the use of the drug as a result of
communication failure (Leape et al., 1993). The report noted that manage-
ment of complex drug therapies, especially in elderly patients, is extremely
difficult and requires special attention to the ability of the patient to under-
stand and remember the amount and timing of dose, as well as behavioral
modifications required by the regimen (e.g., dietary restrictions) (IOM,
2000). The ability of patients and consumers to manage their own health
and medical care can be improved through better provider–patient commu-
nication and greater inclusion of the patient in treatment decisions, as
discussed in Chapter 6 (Hausman, 2001; Hayes-Bautista, 1976; Hulka et
al., 1975, 1976; Miller, 1975; Snyder et al., 1976).
HEALTH LITERACY AS A PUBLIC CONCERN

In its report Healthy People 2010, the U.S. Department of Health and
Human Services included improved consumer health literacy as Objective
11-2, and identified health literacy as an important component of health
communication, medical product safety, and oral health (HHS, 2000). The
importance of health literacy has also been recognized globally. The World
Health Organization has included health literacy as a key factor in health
promotion (WHO, 2000), and the U.S. Agency for International Develop-
ment (U.S. AID) has recognized health literacy as an important contributor
in the move towards a healthier society (U.S. Agency for International
Development, 2001). Much of the pioneering work in health literacy arose
from the fields of health education and health communication in the 1970s
and 1980s (Rudd et al., 2000).
Health literacy is intimately linked to many issues of critical impor-
tance to the nation and to our health policies. The public health mandate of
protecting the health of the nation relies on communication strategies for
issues as different as obesity and bioterrorism. Health literacy is of concern
to people addressing worker health and safety, product labeling, environ-

26 HEALTH LITERACY
mental health, patient rights and responsibilities, quality of care, or access

to information, insurance, and services (Hausman, 2001; Hayes-Bautista,
1976; Hulka et al., 1975, 1976; Rudd et al., 2003; Snyder et al., 1976).
Crossing the Quality Chasm: A New Health System for the 21st Cen-
tury (IOM, 2001) proposed a reorganization of the complex health system
practices that decrease patient safety. The report stressed that the “patient-
centered” approach should be implemented to ensure that patients have a
full understanding of all of their options (IOM, 2001). Limited health
literacy is often unreported by patients, unappreciated by policy makers
and health-care workers, and unappreciated by the general public. Without
improvements in health literacy, the promise of many scientific advances to
improve health outcomes will be diminished. Consequently, the IOM has
identified improving health literacy as one of two cross-cutting issues in
health care needing attention in its recent report, Priority Areas for Na-
tional Action: Transforming Healthcare Quality (IOM, 2003b). This report
called for increased attention to culturally and socially sensitive communi-
cation to improve the overall quality of health care and the health of
minority and lower-income patients.
CHARGE TO THE COMMITTEE

Although a greater appreciation for the potential consequences of lim-
ited health literacy has been developing over recent years, the health field
has lacked a comprehensive yet concise summary of what is known about
health literacy and what needs to be done. Watters (2003) suggests that an
interdisciplinary literacy model that addresses health, literacy, and culture
could successfully guide development, diffusion, and adoption of appropri-
ate information.
In 2002 the IOM convened the Committee on Health Literacy for a
project sponsored by the American Association of Family Physicians Foun-
dation, the California HealthCare Foundation, the Commonwealth fund,
the Kellogg Foundation, the Metlife Foundation, the National Cancer Insti-
tute, the Pfizer Corporation, and the Robert Wood Johnson Foundation.
Committee membership included individuals with expertise in public health,
primary medical care, health communication, sociology, nursing, anthro-
pology, adult literacy education, and K-12 education. As reflected by the
composition of the committee, many academic fields can inform health
literacy inquiries, and have contributed to our understanding of the area.
The committee was carefully selected to ensure that it possessed appropri-
ate expertise for assessing past efforts to promote health literacy and for
providing options to overcome the obstacles to health literacy in future
endeavors. Furthermore, the committee represents a balance of intellectual
perspectives and experiences, ranging from practical experience in promot-

INTRODUCTION 27
ing health literacy to research and theoretical experience in the closely

related fields such as anthropology, psychology, and education. The chair
brought to the study experience with health-care systems and population
health determinants as well as with committee processes. For further infor-
mation regarding the backgrounds of the members of the committee, the
reader is directed to the short biographies presented in Appendix D. The
committee was asked to assess the problem of health literacy and come to
consensus on the next steps, addressing the following charge:
• Define the scope of the problem of health literacy. The intent is to

clarify the root problems that underlie health illiteracy. This would include
identifying affected populations and estimating the costs for society. De-
velop a set of basic indicators of health literacy to allow assessment of the
extent of the problem at the individual, community, and national levels.
• Identify the obstacles to a creating a health-literate public. These
are likely to include the complexity of the health-care system, the many and
often-contradictory health messages, rapidly advancing technologies, limits
within public education to promote literacy of adults as well as children,
etc.
• Assess the approaches that have been attempted to increase health
literacy both in the United States and abroad. Identify the gaps in research
and programs that need to be addressed. The focus should be on public
health interventions attempting to increase health literacy of the public as
well as on improving health provider/primary care interactions. Identify
activities that could improve health literacy with special attention to Med-
icaid and Medicare patients.
• Identify goals for health literacy efforts and suggest approaches for
overcoming obstacles to health literacy in order to reach these goals. Ap-
proaches might include research or policy initiatives, interventions, or col-
laborations that would promote health literacy.
SCOPE OF THE REPORT

This report explores what is known about the epidemiology of limited
health literacy and promising approaches for increasing health literacy. It
offers a conceptual framework for thinking about how society, culture, and
the health and education systems contribute to the problem and to possible
solutions. Throughout, the report seeks to put a human face on the problem
of limited health literacy. Each chapter aims to provide new directions and
blend knowledge from divergent areas of inquiry. Overarching recommen-
dations are presented at the end of the report.
Chapter 2 clarifies the concept of health literacy by discussing its defi-
nition and delineating literacy and functional literacy within the context of

28 HEALTH LITERACY
health. A conceptual model of health literacy is presented with a visual

framework that makes clear that health literacy is a function of the interac-
tion between individuals and the health contexts to which they are exposed.
In addition, the committee outlines limitations to the conceptualization and
measures of health literacy. By these means, the strengths and weaknesses
of existing measures of literacy and health literacy are examined, with a
view toward continued development of health literacy assessment, includ-
ing population indicators and measures of health literacy within health
systems.
Although the charge to the committee included the development of a
set of basic indicators of health literacy, the committee determined that to
do so within the context and limitations of the current knowledge and
available measures would be premature and inappropriate. Development of
population-level public health indicators cannot precede the development
of adequate individual-level measures. The committee limited its findings
and recommendations to suggestions that could promote the development
of improved measures and new basic indicators of health literacy, rather
than developing the indicators themselves. The committee hopes that future
research will enable the development of these indicators.
Chapter 3 reviews the extent and associations of limited health literacy
as currently measured, exploring the broad social effect of disparities be-
tween health literacy needs and demands. This chapter provides insight into
the relationship of the health consumer and health literacy. Current re-
search related to the associations of limited health literacy is summarized,
both in terms of individual health behaviors and outcomes, and in terms of
the financial, legal, and regulatory consequences in health contexts. This
chapter contains extensive tables on the epidemiology of health literacy
skills in various populations and the characteristics and associations of
limited health literacy.
Chapter 4 explores the web of culture and health literacy, and how
these encompass patient perspectives and quality of care, with attention to
clinical uncertainty, patient safety, and the building of health literacy into
standard health care. The interrelationships among culture, language and
meaning, and health literacy measures are discussed as well as culturally
based approaches to improving health literacy.
Chapter 5 explores health literacy within the context of educational
systems and seeks to understand the roles that K-12, university, adult, and
health professional education systems can take to improve health literacy.
In particular, the chapter addresses difficulties encountered by educators in
the K-12 system, and explores possible approaches to improving health
literacy by integrating health into curricula.
Chapter 6 discusses health literacy within the context of the health-care
system, including providers, insurers, administrators, national agencies that

INTRODUCTION 29
guide health policy, and others. Current issues facing health care are dis-
cussed as they relate to health literacy. The chapter also reviews various
types of approaches that may help to address the problem of limited health
literacy when applied in health care settings.
Chapter 7 presents the committee’s vision for a health literate society.
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Watters EK. 2003. Literacy for health: An interdisciplinary model. Journal of Transcultural
Nursing. 14(1): 48–54.
WHO (World Health Organization). 2000. Health Promotion. Report by the Secretariat.
World Health Organization.

What Is Health Literacy?
A 29-year-old African-American woman with three days of abdominal pain

and fever was brought to a Baltimore emergency department by her family.
After a brief evaluation she was told that she would need an exploratory
laparotomy. She subsequently became agitated and demanded to have her
family take her home. When approached by staff, she yelled “I came here in
pain and all you want is to do is an exploratory on me! You will not make me
a guinea pig!” She refused to consent to any procedures and later died of
appendicitis.
DEFINITION OF HEALTH LITERACY

Health literacy is of concern to everyone involved in health promotion
and protection, disease prevention and early screening, health care and
maintenance, and policy making. Health literacy skills are needed for dia-
logue and discussion, reading health information, interpreting charts, mak-
ing decisions about participating in research studies, using medical tools for
personal or familial health care—such as a peak flow meter or thermom-
eter—calculating timing or dosage of medicine, or voting on health or
environmental issues. This report makes use of the operational definition of
health literacy developed for the National Library of Medicine and used by
Healthy People 2010:
31

32 HEALTH LITERACY
The degree to which individuals have the capacity to obtain, process, and
understand basic health information and services needed to make appro-
priate health decisions (Ratzan and Parker, 2000).
The capacity of the individual is a substantial contributor to health
literacy. The term “capacity” refers to both the innate potential of the
individual, as well as his or her skills. An individual’s health literacy capac-
ity is mediated by education, and its adequacy is affected by culture, lan-
guage, and the characteristics of health-related settings. In this report, the
committee has captured the range of environments and situations related to
health in the term “health context”. The health context includes the media,
the marketplace, and government agencies, as well as those individuals and
materials a person interacts with regarding health—all must be able to
provide basic health information in an appropriate manner (Rudd, 2003).
This health context is of equal importance to individuals’ health literacy
skills, as the impact of health literacy arises from the interaction of the
individual and the health context (Rudd, 2003; Rudd et al., 2003). Health
literacy, then, is a shared function of cultural, social, and individual factors.
Both the causes and the remedies for limited health literacy rest with our
cultural and social framework, the health and education systems that serve
it, and the interactions between these factors.
A Conceptual Framework for Health Literacy

Figures 2-1 and 2-2 provide visual frameworks for considering health
literacy. Figure 2-1 places literacy as the foundation of health literacy and
health literacy as the active mediator between individuals and health con-
texts. Individuals bring specific sets of factors to the health context, includ-
ing cognitive abilities, social skills, emotional state, and physical conditions
such as visual and auditory acuity. Literacy provides the skills that enable
individuals to understand and communicate health information and con-
cerns. Literacy is defined as a set of reading, writing, basic mathematics,
speech, and speech comprehension skills (Kirsch, 2001a). Health literacy is
the bridge between the literacy (and other) skills and abilities of the indi-
vidual and the health context. This interaction is explored in Chapter 3,
where associations between health literacy and health-related outcomes are
discussed in detail.
Figure 2-2 illustrates the three key sectors that should assume responsi-
bility for health literacy, and within which health literacy skills can be built.
The sectors that constitute the contexts of health literacy are culture and
society, the health system, and the education system. These sectors also
provide intervention points that are both challenges and opportunities for

WHAT IS HEALTH LITERACY? 33
Health Literacy Framework
Health
Literacy Health
Contexts
Outcomes
and Costs
Health
Literacy
Individuals
FIGURE 2-1 Health literacy framework.
Figure 2-2 illustrates the interaction of individuals with education sys-

tems, health systems, and societal factors as they relate to health literacy. It
is not a causal model. It is likely that the determinants of health literacy are
as varied and complex as those of the most refractory problems now facing
the health fields. Although causal relationships between limited health lit-
eracy and health outcomes are not yet established, cumulative and consis-
tent findings suggest such a causal connection. Research is needed to estab-
lish the nature of the causal relationships between and among these factors.
Mapping this web of causation should be a goal of research, but it is
important to note that current knowledge can serve as the basis for chang-
ing practice and policy. Below, we introduce the role each of the sectors
plays in supporting or impairing health literacy. The opportunities for and
obstacles to health literacy in these three sectors will be discussed in detail
in Chapters 4, 5, and 6.
Culture and Society

The term “culture” in this report primarily refers to the shared ideas,
meanings, and values acquired by individuals as members of society. Cul-
tural, social, and family influences are of critical importance in shaping
attitudes and beliefs. In this way, they influence how people interact with
the health system and help determine the adequacy of health literacy skills
in different settings. People know humanity, deal with the world they live
in, and understand their place in the universe through cultural processes.
Conditions over which the individual has little or no control but which

34 HEALTH LITERACY
Potential Intervention Points

2
Health
System Health
1 Outcomes
and Costs
Culture
and Health
Literacy
Society
Education
System
3
FIGURE 2-2 Potential points for intervention in the health literacy framework.
affect the ability to participate fully in a health-literate society comprise

social determinants of health. Included are native language, socioeconomic
status, gender, race, and ethnicity, along with influences of mass media as
represented by news publishing, advertising, marketing, and the plethora of
health information sources available through electronic sources. Culture is
crucial for understanding, thinking, and responding to human experiences
and world events. American culture is formed from historical, racial-ethnic,
social, political, psychological, educational, and economic forces that are
woven into the context of American lifestyles. Because they are pathways to
understanding American life, cultural contexts should be harnessed in the
quest for a health-literate America.
The Education System

The education system in the United States consists of the K-12 system,
adult education programs, and higher education. K-12 education is charged
with the development of literacy and numeracy skills in English, which
cumulatively form the foundation for more complex skills involving com-
prehension and application in the later grades. Adult education programs

provide opportunities for individuals who drop out of K-12 education for
academic or social reasons, for those who completed high school but did
not acquire strong skills, for elders who did not have full schooling oppor-
tunities, and for adult immigrants who may never have had access to educa-
tion and/or wish to learn to speak, read, and write English. Individuals with
college-level education or higher frequently have adequate literacy skills,
and generally are not discussed in this report. Formative and continuing
education for health professionals is also considered within the context of
education.
The Health System

Within the many components of health-care systems, health-related
messages and action plans are crafted, rights and responsibilities are shaped,
research initiatives are begun, health-promoting recommendations are de-
veloped and supported, access is monitored, and regulations are enforced.
In this report, we use the term health system to refer to all people perform-
ing these activities, including those working in hospitals, clinics, physician’s
offices, home health care, public health agencies, accreditation groups, regu-
latory agencies, and insurers. Published reviews of the literature (for ex-
ample, see Kerka, 2000; Rudd et al., 2000) and the committees research
into the literature from a range of related fields, including health communi-
cation and social marketing, provide consistent evidence supporting the
notion that health literacy affects the interaction of individuals with health
contexts and the health-care system, and may further affect health status
and outcomes.
Finding 2-1 Literature from a variety of disciplines is consistent in

finding that there is strong support for the committee’s conclusion that
health literacy as defined in this report is based on the interaction of indi-
viduals’ skills with health contexts, the health-care system, the education
system, and broad social and cultural factors at home, at work, and in the
community. The committee concurs that responsibility for health literacy
improvement must be shared by these various sectors. The committee notes
that the health system does carry significant but not sole opportunity and
responsibility to improve health literacy.
Finding 2-2 The links between education and health outcomes are
strongly established. The committee concludes that health literacy may be
one pathway explaining the well-established link between education and
health, and warrants further exploration.

36 HEALTH LITERACY
The Scope of Health Literacy

If people who promote health care, create policy, and develop health
materials have a clear understanding of the problem of health literacy,
procedures, policies, and programs can be developed to meet the health
literacy needs of the average American adult. A clear understanding of
health literacy can guide the health system of public health practitioners,
care providers, insurers, and community agencies toward adopting defini-
tions and policies that resolve incompatibilities between the needs of indi-
viduals and the demands of health systems. The committee believes that
both a commonly accepted definition and a conceptual framework will
contribute to the clear understanding of health literacy. In choosing the
definition and developing the framework in this report the committee exam-
ined the existing definitions and concepts of health literacy. The committee
believes the definition and framework in this report incorporate aspects
essential to the understanding of health literacy, and allow for a flexibility
of response within the framework of a widely accepted definition.
Health literacy is a newly emerging concept and field of inquiry, so it is
not surprising that the scope of health literacy varies according to how it is
defined. For example, in 1999, the Ad Hoc Committee on Health Literacy
of the American Medical Association defined health literacy as the “con-
stellation of skills, including the ability to perform basic reading and nu-
merical tasks required to function in the health care environment,” and
included everyday health functions such as the “ability to read and compre-
hend prescription bottles, appointment slips, and other essential health-
related materials” (American Medical Association, 1999). This definition
captures important components of health care, but confines the scope of
health literacy to the health-care sector. This committee extends the con-
cept of health literacy beyond health-care settings to include the variety of
contexts (such as in the community and at work) in which individuals make
health-related decisions.
Another concept of health literacy is found in the definition used by the
Joint Committee on National Health Education Standards: “the capacity of
individuals to obtain, interpret and understand basic health information
and services and the competence to use such information and services in
ways which enhance health” (Joint Committee on National Health Educa-
tion Standards, 1995). This definition does move beyond the health-care
setting; however, this and similar definitions (e.g., Kickbusch, 1997) main-
tain a focus on the capacity of individuals and emphasize the characteris-
tics, knowledge, and skills of individuals without attention to the complex-
ity of various health contexts, the tasks involved, or the materials in use.
The committee chose to adopt the definition used in Healthy People
2010 for purposes of measurement and clarity in this report. As previously

noted, Healthy People 2010, the document that reports the federal govern-
ment’s national health objectives, defines health literacy as “the degree to
which individuals have the capacity to obtain, process, and understand
basic health information and services needed to make appropriate health
decisions” (HHS, 2000; Ratzan and Parker, 2000). This definition is useful
because it encompasses the variety of contexts within which individuals
may confront and interact with health issues. As with a number of the other
definitions discussed above, however, it focuses attention on and appears to
limit the problem of health literacy to the capacity and competence of the
individual. This limitation is acknowledged and addressed in the action
plan for the Healthy People 2010 health literacy objective, which expands
the definition to include system-level contributions (Rudd, 2003). Recog-
nizing the limitations of this definition, the committee acknowledges the
need for future development of definitions and measures that address the
critical role that society, the health system, and the education system play in
creating a truly health-literate America.
DEFINITION OF LITERACY
Educators do not associate literacy with reading alone, but often con-
sider literacy to represent a constellation of skills including reading, writ-
ing, basic mathematical calculations, and speech and speech comprehension
skills (Kirsch, 2001a). Speech and speech comprehension are collectively
termed oral literacy, while reading and writing are referred to as print
literacy. For our discussion in this report, we further differentiate among
the following terms: basic print literacy, literacy for different types of text,
and functional literacy. Basic print literacy ability means the ability to read,
write, and understand written language that is familiar and for which one
has the requisite amount of background knowledge. Reading or text lit-
eracy is related to characteristics of the text being read such as complexity
and format. Functional literacy is the use of literacy in order to perform a
particular task. We note that health literacy has been variously defined, but
as currently used and measured, often consists of reading or text literacy
(see below for further discussion). Figure 2-3 below illustrates the relation-
ships between the different contributors to literacy.
As illustrated above in Figure 2-3, a consideration of health literacy
must include component parts directly related to the broad concept of
literacy. Literacy, as noted earlier, is context specific. For example, literacy
could be placed within the multiple health contexts noted earlier. In this
case, the construct includes cultural and conceptual knowledge that could
include an understanding of health and illness and a conceptualization of
risks and benefits. Listening and speaking skills are essential for public
health communication, the commercial sector’s advertising goals, and for

38 HEALTH LITERACY
Contexts
Literacy
Cultural and Listening Speaking Writing Reading Numeracy

Conceptual
Knowledge
Oral Print
Literacy Literacy
FIGURE 2-3 Components of literacy.
practitioner–patient interactions, such as for the presentation of symptoms

critically needed for diagnosis. Writing and reading skills, often called print
literacy, are needed for tasks related to the use of the printed word, whether
the words are found on labels in the market, in health education brochures,
on medicine bottles or in informed consent documents. Numeracy skills are
needed to calculate nutrition labels, calibrate temperature, and compare
benefit packages, and for determining the proper dosage and timing of
medicines. The committee recognizes that these skills are essential compo-
nents of health literacy. However, most literature focused on health literacy
issues has focused predominantly on assessments of materials and on mea-
sures of people’s skills based on their ability to read a sample of these
materials. Thus, print literacy has dominated the discussion in health lit-
eracy so far. At the same time, the focus on print literacy has yielded
profound insights into difficulties and barriers linking literacy skills to
health outcomes.
Finding 2-3 Health literacy, as defined in this report, includes a vari-

ety of skills beyond reading and writing, including numeracy, listening, and
speaking, and relies on cultural and conceptual knowledge.
Basic Print Literacy

As mentioned earlier, basic print literacy ability means the ability to
read, write, and understand written language that is familiar and for which

one has the requisite amount of background knowledge. It includes the

ability to decode letters and sound out words, but also includes the ability
to understand the meaning of the printed text. Some people with limited
skills may know how to decode letters into sounds and pronounce words
but may not be able to understand the meaning of a sentence formed by
these words. However, as many new readers build on these skills, they learn
how to read words in sentence sequence and accumulate levels of fluency
for reading and writing. Fluency in reading includes accuracy, rate, and
appropriate phrasing and intonation. Fluent reading “sounds” natural
rather than halting and effortful. Basic print literacy is what is referred to
when someone inquires, “can he read?” People who are termed “illiterate”
have few, if any, of the skills needed for basic print literacy. The terms “low
literate” or “limited” reading skills refer to difficulty with reading and
comprehending materials written beyond very simple levels.
Literacy for Different Types of Text

Possessing the skills needed for basic literacy does not guarantee that
one can read and comprehend all types of written text. Readers must know
and understand the individual words and terms used in the text and be
familiar with the concepts addressed in the text. They must understand how
to “read” the structure of the text. For example, a prescription label has a
unique structure and the reader must be able to use that structure to under-
stand the directions that follow. The reader may be helped or hindered by
various text features such as font size, layout and design, syntax, or use of
graphs. Not all texts are equally readable and comprehensible to every
person, regardless of that person’s reading ability. The same literate person
who can read the daily newspaper, the Bible, novels, or a manual at work
may not be able to figure out instructions for connecting a DVD player to a
television, directions for taking medicine, a blueprint for a new skyscraper,
or the bias in an editorial. Thus, the readability of different texts depends
on the skills and background knowledge of individual readers, factors in
the text, and the purpose for which readers use the materials.
All Literacy is Functional

Texts serve specific functions, and readers come to them in order to
accomplish specific tasks. At times, the task at hand may be clear; for
example, a person is most likely to read a bus schedule in order to deter-
mine when the bus is arriving at a certain place. In other cases, the task
may be less clear; a person is most likely to read a novel for pleasure. In
both examples, however, the person is applying literacy skills to perform a
function.

40 HEALTH LITERACY
The content and structure of a bus schedule is meant to be a reflection

of the function it serves to help a traveler plan an excursion. A bus schedule
generally lists the routes and stops of different buses—often identified with
numbers—for people who need to plan their transportation and arrive at a
particular destination at a specific time. More complicated schedules in-
clude variations based on days of the week or holiday exceptions. Similarly,
the content and structure of a label on a pediatric over-the-counter medi-
cine is designed to provide the parent with information about the medicine
and a mechanism for calculating the appropriate dose based on the child’s
age and weight. This information is often present in a table format that
requires special reading skills that many people do not have.
An individual’s ability to apply his or her literacy skills changes with
the challenges of the task (Kirsch, 2001b; Kirsch et al., 1993). The example
below, the text of an actual letter sent by a doctor to a patient, captures a
very complicated message. Although the patient in this case holds a gradu-
ate degree, his anxiety was greatly increased as a result of a confusing
message. He asked, “How can I have a recurrence of thyroid cancer if my
thyroid was removed?”
Dear Mr. Smith,
The May thyroid tests showed TSH 2.794 µU/ml, which, though “normal,” is
too high for someone who has had prior thyroid carcinoma. Keeping TSH
between 0.1 – 0.3 µU/ml minimizes recurrence of thyroid cancer. Free T4
1.60 mg% is a high-normal level.
I suggest you increase L-thyroxine from 150 mcg 7 days a week to 150 mcg
5 days a week and 225 mcg (11⁄2 tablets) Wednesdays and Sundays weekly.
Have a repeat TSH, free T4 and total T3 in 8 weeks. I should also on that
occasion like you to have a serum plasma metanephrine level.
Two weeks after having those tests, please see me for a consultative office
visit.
Sincerely yours,
John Doe, M.D.
Endocrinology

LITERACY IN HEALTH CONTEXTS

Health-related activities take place in a wide variety of settings (home,
work, community health-care institutions) and can involve a wide range of
activities related to family, community, economics, leisure, and safety is-
sues. The parent taking a child’s temperature, the worker reading about
proper procedures for handling materials, the shopper calculating the dif-
ference in salt content on the labels of two brands of canned vegetables, the
patient reading about dental options, and the elder filling out an applica-
tion for Medicare are all engaged in health-related tasks, in different envi-
ronments, for different purposes, and with different types of materials. All
are applying literacy skills to printed health information.
This report uses the term “health contexts” to reflect the many situa-
tions and activities relating to health. Health contexts are unusual, com-
pared to other contexts, because of an ever-present or underlying stress or
fear factor. Various exposures, products, or actions might enhance health,
safeguard health, harm health, or lead to very dire consequences. In addi-
tion, health-care settings can involve unique conditions such as the physical
or mental impairment experienced by a patient due to illness, stress, or fear
(Alexander, 1990; Dumas, 1966). Health-care settings also involve special-
ized vocabulary, use of jargon, legal forms, complex procedures and pro-
cesses, as well as differences in power and access to information.
Literacy Skill Demands of Health Contexts

A complex array of health literacy skills are needed for functioning in a
variety of health contexts. These skills include reading, writing, mathemat-
ics, speaking, listening, using technology, networking, and rhetorical skills
associated with requests, advocacy, and complaints. Table 2-1 presents
some brief (and incomplete) examples to provide a sense of the complexity
of skills needed for health.
While many of the examples presented in Table 2-1 emphasize the skills
of individuals, the skills of those communicating also contribute to health
literacy. We must consider a health-care provider’s ability to use common
words and to perceive whether a patient is understanding a discussion or
not. A media developer needs the skills to shape a message that consumers
can understand. Manufacturers need skills to design clear product labels.
Educators need skills to engage students in health-related issues and to
incorporate health messages into science, language, and math curricular
materials. The example below represents the level of confusion created by a
lack of clear information, even for the most educated consumer.

42 HEALTH LITERACY
TABLE 2-1 Examples of Skills Needed for Health

Health-Related Goal Sample Tasks and Skills Needed
Promote and protect • read and follow guidelines for physical activity
health and prevent • read, comprehend, and make decisions based on food and
disease product labels
• make sense of air quality reports and modify behavior as
needed
• find health information on the internet or in periodicals
and books
Understand, interpret, • analyze risk factors in advertisements for prescription

and analyze health medicines
information • determine health implications of a newspaper article on
air quality
• determine which health web sites contain accurate
information and which do not
• understand the implications of health-related initiatives in
order to vote
Apply health • determine and adopt guidelines for increased physical

information over a activity at an older age
variety of life events • read and apply health information regarding childcare or
and situations eldercare
• read and interpret safety precautions at work; choose a
health-care plan
Navigate the health- • fill out health insurance enrollment or reimbursement

care system forms
• understand printed patient rights and responsibilities
• find one’s way in a complicated environment such as a
busy hospital or clinical center
Actively participate in • ask for clarification

encounters with health- • ask questions
care professionals and • make appropriate decisions based on information
workers received
• work as a partner with care providers to discuss and
develop an appropriate regimen to manage a chronic
disease
Understand and give • comprehend required informed consent documents before

consent procedures or for involvement in research studies
Understand and • advocate for safety equipment based on worker right-to-

advocate for rights know information
• request access to information based on patient rights
documents
• determine use of medical records based on the privacy act
• advocate on behalf of others such as the elderly or
mentally ill to obtain needed care and services

A highly publicized, large-scale study of combination estrogen-progestin

hormone therapy by the Women’s Health Initiative came to a sudden end in
the summer of 2002 when researchers noticed higher levels of heart disease,
blood clots and breast cancer in the group taking hormones.
According to Wyeth spokeswoman Natalie DeVane, 15 million American

women were taking some form of hormone treatment before the study was
stopped. This past June, she said, the number was 9.2 million.
Rep. Rosa L. DeLauro (D-Conn.) led the effort to mandate an FDA education
effort on hormone therapies. “I’m pretty well-informed about these things,
and I didn’t know what to do,” she said. “In the absence of clear information,
it can get pretty scary for women.” (Kaufman, 2003)
MEASURES USED IN HEALTH LITERACY RESEARCH

Measures of literacy are needed to allow us to assess people’s literacy
competence and to suggest promising intervention points and strategies.
However, we must recognize that assessment of literacy ability (as for any
assessment) depends on how literacy is defined and how assessment results
are to be used. Literacy assessment has evolved over the years and takes
several different forms, resulting in the necessity to interpret and use the
results accordingly.
Literacy Surveys
Assessments of adult literacy conducted since the late 1980s have fo-
cused on functional literacy and numeracy as outlined by the National
Literacy Act of 1991.1 This act defines literacy as “the ability to read, write,
and speak in English, and compute and solve problems at levels of profi-
ciency necessary to function on the job and in society, to achieve one’s
goals, and develop one’s knowledge and potential.” This definition was
applied to the development of the national assessments of adult literacy in
the United States and other industrialized nations. The surveys measured
three of the five accepted components of literacy: reading, writing, and
mathematical calculations (or numeracy). Oral language skills, including
speaking and listening, were not assessed for the national studies, in part
because of time constraints and a possible burden on participants (Kirsch,
1P.L. 102-73, The National Literacy Act of 1991. 102nd Congress, 1st Session. H.R. 751.

44 HEALTH LITERACY
2001a). The Young Adult Literacy Survey (performed in 1985) (Kirsch and
Jungeblut, 1986), the Department of Labor Survey (1990) (Kirsch and
Jungeblut, 1992), the National Adult Literacy Survey (NALS) (1992)
(Campbell et al., 1992), and the International Adult Literacy Survey (IALS)
(the initial study was performed in 1994–1998) (Kirsch, 2001a) all focus on
the ability to use print materials to accomplish a task. These task-oriented
assessments differ in complexity from basic literacy assessments that focus
on the ability to recognize or pronounce words, or to read and comprehend
text written specifically for test purposes.
Materials for these surveys were drawn from six contexts in order to
represent literacy tasks from everyday life: home and family, health and
safety, community and citizenship, consumer economics, work, and leisure
and recreation. Materials included both continuous and noncontinuous
texts. Continuous texts or prose, which is the term used in these large-scale
assessments, are typically composed of sentences that are, in turn, orga-
nized into paragraphs. These paragraphs are used to form larger structures
such as stories, newspaper or magazine articles, and even sections or chap-
ters in a book. A common way of organizing continuous texts is by their
rhetorical structure. These might include: narratives, exposition, descrip-
tion, argumentation, instructions, or a document and record. Noncontinu-
ous texts or documents as they are referred to involve the display of infor-
mation using other structures or formats. These might include tables, charts,
graphs, entry forms, maps, and diagrams. They have been described by
Mosenthal and Kirsch (1998) and Kirsch (2001b). These materials range in
both length and complexity. Some prose materials are very short such as a
brief sports article or letter. Others are more lengthy and complex such as
an editorial. Documents, too, range in length and complexity such as a
social security card on which someone has to enter their signature to a
complex table showing the results of a survey or an embedded bus schedule.
NALS scores were based on people’s ability to accomplish tasks using
printed texts. The difficulty of each task was related to three variables: type
of match, type of information, and plausibility of distracting information
(Kirsch, 2001a). Four types of matching strategies were identified: locating,
cycling, integrating, and generating.
The tasks, in ascending order of difficulty, included:
• Locating—requires the reader to find information based on condi-

tions or features specified in the text or document.
• Cycling—requires the reader to engage in a series of matching or
locating operations that involve the strategy of locating.
• Integrating—requires the reader to pull together pieces of informa-
tion from a text or document often times having to compare or contrast this
information.

• Generating—requires the reader to produce a response either by

making a text-based inference or by drawing on their background knowl-
edge.
• Formulating and Calculating—requires the reader to identify both
the numbers or quantities and the operation that must be performed. If
more than one operation is required, the reader must determine the appro-
priate order of the operations.
Tasks were further identified by specific characteristics: type of match,

type of information requested, plausibility of distracters, type of calcula-
tion, and operation specificity. Detailed discussions of how these factors
contributed to scoring may be found in the International Adult Literacy
Survey: Understanding What Was Measured (Kirsch, 2001b).
Findings reported participants’ ability to complete these tasks with 80
percent accuracy and consistency for three types of literacy: prose (tasks
involving materials using full sentences in paragraph format), document
(tasks involving materials consisting of lists, graphs, and charts), and numer-
acy (quantitative literacy; tasks involving the application of basic math-
ematical processes). Assessments were scored on a 0 to 500 scale and
findings were reported by score for various population groups and by
levels:
• Level 1 (score of 0 to 225): Many adults at this level can perform

tasks involving brief and uncomplicated texts and documents. Adults at this
level can generally locate a piece of information in a news story or on a
form such as a social security card.
• Level 2 (score of 226 to 275): Adults at this level of proficiency are
generally able to locate information in text, make low-level inferences using
printed materials, and integrate easily identifiable pieces of information.
• Level 3 (score of 276 to 325): Adults at this level are able to
integrate information from relatively long or dense texts or documents,
determine appropriate arithmetic operations based on information con-
tained in the directive, and identify quantities needed to perform the opera-
tion.
• Levels 4 (score of 326 to 375) and 5 (score of 376 to 500): Adults
at these levels demonstrate proficiencies associated with long and complex
documents and text passages.
Grade-Level Measures of Literacy

One of the most familiar terms associated with the assessment of read-
ing levels is that of grade level. This term is used in two different ways.
First, individual scores on assessments of reading achievement are often

46 HEALTH LITERACY
reported in terms of grade level, for example, He scored a Grade Equivalent

(GE) of 5.2. The second way that grade level is used is to indicate the
readability level of a text, for example, the story was written at a fifth grade
level. The two uses of the term grade level, while related, do not mean the
same thing. The first refers to a norm-referenced score on a norm-refer-
enced reading achievement test and applies to individuals. The second is the
result of applying a formula for reading ease to written materials and
applies to texts.
Grade-Level Ability for Individual Readers

Within the area of assessment and psychometrics, the construct of
grade level indicates relative placement of an individual or group score on a
norm-referenced test, that is, a test designed so that an individual’s score
can be established by comparison to the test scores of a representative
sample of persons. Grade level is one type of transformed score. Others
include percentiles, stanines, and standard scores. While these other trans-
formed scores indicate specific locations on a bell-shaped normal curve of
scores of a sample of previously tested individuals (the norm sample), grade-
level scores do not, and therefore the potential for their misinterpretation is
higher. Statistically, the grade-level score is derived from the mean score on
a norm-referenced test. This means that the average raw score on a norm-
reference achievement test for a given grade is transformed into the grade-
level score for that grade. For example, if the average score attained by fifth
graders in the norm sample on a norm-referenced reading achievement test,
taken in the second month of fifth grade, is 75 (out of, say 100), then the
score of 75 will be assigned a grade-level score of 5.2 (fifth year, second
month). Therefore, one can say with accuracy that a student who scores on
grade level is achieving, according to this test, on average. All other scores,
both lower and higher, on this test are transformed into grade-level scores
through a process of mathematical extrapolation. Thus, a grade-level score
(GE; grade equivalency) of 3.5 for a fifth grader on this test indicates a
certain distance below the average score; a GE of 7.2 correspondingly
indicates a certain distance above the average score. The appropriate inter-
pretation of the on-grade-level, or average, score is as a measure of the
student’s ability to read material at his or her current grade level. Above-
and below-grade-level scores are less reliable due to the extrapolation in-
volved. This is due to their extrapolation from raw scores.
Studies that examined the reading ability of the intended audience,
performed in the 1980s and early 1990s, frequently assessed reading ability
with short-word recognition tests, Cloze tests (in which random words
from a passage are deleted; Taylor, 1953), or other reading comprehension
tests. These types of assessments of literacy typically result in the assign-

ment of a grade-level score, and are frequently used by adult educators to

place adult students in appropriate level classes. One of these assessments,
the reading recognition subtest of the Wide Range Achievement Test-
Revised (WRAT-R) requires participants to read aloud lists of words that
become increasingly difficult. The test is stopped when 10 words have been
consecutively mispronounced (Jastak and Wilkinson, 1984). The Instru-
ment for Diagnosis of Reading, also known as the Instrumento Para Diag-
nostical Lecturas (IDL), is another test commonly used to assess reading
ability. Although the IDL is lengthy, taking more than 20 minutes to ad-
minister, it is useful because it was developed in the Spanish language and
provides a comprehensive assessment of reading comprehension in Spanish
(Blanchard et al., 1989). A shortened form is available that takes about 7
minutes to administer.
Grade-Level Measures of Materials

Well over 300 articles in public health and medical journals focus on
the assessment of various types of health-related materials (Roter et al.,
2001; Rudd, 2003; Rudd et al., 2000). Many researchers used readability
score to indicate text complexity. A commonly used formula for readability
score is the Simplified Measure of Gobbledygook (SMOG) which is based
on calculations of the number of polysyllabic words in a set number of
sentences. Consequently, the SMOG focuses on sentence and word length,
both of which are associated with reading ease or difficulty (McLaughlin,
1969). Other commonly used assessment measures include the Fry Read-
ability Scale (Fry, 1977) and the Flesch-Kincaid Reading Grade Level
(Flesch, 1974). Measures of reading levels probably required to understand
different materials have contributed to the research agenda in health lit-
eracy by providing initial indications of text complexity, based on words
and sentence length. These determinations of reading level are valuable
when considered in light of the audiences for the material.
Measures of Health Literacy

Assessments of print literacy in the context of health were initially
developed in the 1990s. Two frequently used assessments that have been
described in detail are the Rapid Estimate of Adult Literacy in Medicine
(REALM; Davis et al., 1993) and the Test of Functional Health Literacy in
Adults (TOFHLA; Parker et al., 1995).
The REALM is a medical-word recognition and pronunciation test for
screening adult reading ability in medical settings. It can be administered
and scored in under 3 minutes by personnel with minimal training, making
it easy to use in clinical settings. Participants read from a list of 66 com-

48 HEALTH LITERACY
mon medical terms that patients may be expected to be able to read in

order to participate effectively in their own health care. The words are
arranged in three columns according to the number of syllables and pro-
nunciation difficulty. Each correctly read and pronounced word increases
the participant’s score by 1. Scores (0–66 words read and pronounced
correctly) can be converted into four reading grade levels: grades 0–3 (0–
18 words), grades 4–6 (19–44 words), grades 7–8 (45–60 words), and
grade 9 and above (61–66 words). The REALM’s criterion validity is es-
tablished through correlation with other standardized reading tests: Pea-
body Individual Achievement Test-Revised, 0.97 (Markwardt, 1989), Slos-
son Oral Reading Test-Revised, 0.96 (Slosson, 1990), and WRAT-R, 0.88
(Davis et al., 1993, 1998; all correlations p < 0.0001). The REALM also
reports high intra-subject reliability (0.97). The REALM has been devel-
oped in English only. A Spanish-language version is not possible because
reading tests based on pronunciation are not valid in Spanish. This is due
to the regular phoneme–grapheme correspondence of Spanish, in which
there is usually a one-to-one correspondence between letters and sounds,
making it relatively easy to pronounce unfamiliar words even for readers
with limited literacy skills (Nurss et al., 1995).
The TOFHLA includes a 17-item test of numerical ability and a 50-
item test of reading comprehension, as measured by a Cloze procedure (see
Appendix C for examples of items from the TOFHLA). The TOFHLA
draws on materials commonly used in health-care settings at the time the
test was developed. Reading passages were selected from instructions for
preparation for an upper gastrointestinal series, the patient “Rights and
Responsibilities” section of a Medicaid application, and a standard in-
formed consent form. The numeracy items on the TOFHLA test a patient’s
ability to understand monitoring blood glucose, keep a clinic appointment,
obtain financial assistance, and understand directions for taking medicines
using an actual pill bottle.
Total scores for the TOFHLA are divided into three criterion levels:
inadequate, marginal, and adequate. Those with inadequate health literacy
scores often misread medication dosing instruction, appointment slips, and
instructions for the upper gastrointestinal tract radiographic procedure.
Those with marginal health literacy scores perform better on those tasks,
but often misread information on prescription bottles and have trouble
understanding the Medicaid “Rights and Responsibilities” passage. Those
who score in the adequate range do well on these tasks, but may have some
difficulty comprehending the more difficult tasks like determining financial
eligibility and the informed consent document (Parker et al., 1995). The
TOFHLA takes up to 22 minutes to administer and has good criterion
validity, with correlation coefficients of r = 0.74 with the WRAT-R and r =

0.84 with the REALM, and a high reliability (Cronbach’s alpha = 0.98;
Parker et al., 1995).
For time considerations, the TOFHLA was reduced to an abbreviated
version called the S-TOFHLA that takes 12 minutes or less to administer
(Baker et al., 1999). It consists of a reading comprehension section contain-
ing a 36-item test using the initial two passages in the reading comprehen-
sion section of the full TOFHLA—instructions for preparation for an upper
gastrointestinal series and the patient “Rights and Responsibilities” section
of a Medicaid application. It also contains a shortened 4-item measure of
numeracy. The S-TOFHLA has been shown to have good internal consis-
tency reliability (Cronbach’s alpha = 0.98 for all items combined) and
concurrent validity compared to the long version of the TOFHLA (r = 0.91)
and the REALM (r = 0.80). Both the TOFHLA and the S-TOFHLA are
available in English and in Spanish. The Spanish and English versions were
developed simultaneously and use the same standard of measurement.
Additional measures continue to be developed, including a measure of
health literacy in Veterans Administration hospital populations based on
the S-TOFHLA (Chew and Bradley, 2003), a literacy test for patients with
diabetes (Nath et al., 2001), and a functional test of ability to maintain a
medication regimen (Edelberg et al., 1998, 1999, 2001).
The use of these tests of literacy for printed material in the health
context has enabled medical researchers to explore differences among vari-
ous health-related outcomes for patients based on approximations of pa-
tients’ health literacy as indicated by patients’ reading skills for health
materials. As a result, a growing body of research has shown that limited
reading and/or numeracy skills reduce access to health information and
preventive services, reduce understanding of illness and disease, regimens
and medications, and increase outcomes such as hospitalization or decrease
outcomes such as disease management markers. This research is discussed
in detail in Chapter 3.
Limitations of Existing Measures
Functional Literacy Measures

Education scholars consider literacy a changing set of skills, knowl-
edge, and strategies that adults build throughout their lives. As noted ear-
lier, this set of skills includes reading, writing, speaking, listening, and
numeracy (Kirsch, 2001b). However, available assessments of adult literacy
(NALS, IALS, National Assessment of Adult Literacy [NAAL]) do not fully
measure all these aspects of literacy because measurements of oral literacy
skills (including speech and speech comprehension) were considered be-

50 HEALTH LITERACY
yond the scope of what was feasible at the time these surveys were carried
out.
Oral language skills are of critical concern for public health and health
care. Public health and risk communication rely on a variety of channels
and media, including oral communication, to convey health promotion and
protection information, as well as for local and national alerts. Health-care
encounters rely on a dialogue between patient and provider that allow the
provider to understand symptoms, follow the course of an illness or disease
as experienced by the patient, and provide diagnosis and treatment options.
Patients are expected to tell their stories, describe their experiences, provide
explanations, and obtain help with needed action. Given the importance of
speech and speech comprehension skills to health literacy, the current mea-
sures of health literacy that are modeled on previous functional literacy
assessment tools do not tap the full scope of health literacy.
Grade-Level Scores
Grade-level scores are problematic because they require an interpreta-
tion of assessments for the level of ability for individual readers. The use of
grade level as a meaningful norm-referenced score is so problematic that the
International Reading Association recommended that it not be used for K-
12 (Joint Task Force on Assessment, 1994). Its use in adults for whom there
are no “grades” from which to extrapolate from a mean score on a norm-
referenced test is even more inaccurate.
Health Literacy Measures

Although useful for assessment in clinical and community settings,
from a psychometric perspective neither the REALM nor the TOFHLA
capture the full complexity of the construct of health literacy. They are both
measures of basic print literacy using health-related terms, and to some
degree, texts. To this degree, they provide a valid picture of basic print
literacy ability within health contexts. While the TOFHLA also includes a
measure of numeracy, a full range of text types are not included. However,
health literacy includes more than word recognition, text comprehension,
and numeracy skills. Furthermore, health tasks are not limited to the health-
care system but instead comprise a broad spectrum of activities in a variety
of contexts. Therefore, we do not yet possess a measure that takes into
account the full set of skills and knowledge associated with health literacy
as defined in this report. The results of such measures as the REALM and
the TOFHLA must be interpreted in this light.
The TOFHLA includes passages with readability levels on the Gunning
Fog index of grades 4.3, 10.4, and 19.5. However, the TOFHLA, unlike the
NALS, did not examine the complexity of the materials or the difficulty of

tasks involved in the use of the materials. Although both the TOFHLA and
the S-TOFHLA include numeracy tasks, the REALM does not examine
numeracy, and none of these assessments examine writing. The contents of
the REALM and the TOFHLA focus on medical terms or materials found in
medical settings and do not represent the broad spectrum of health literacy
materials and processes that occur outside the clinical setting, limiting the
conclusions that can be drawn. As discussed above, neither considers oral
language skills.
Researchers using existing measures of health literacy have been able
to establish differences in health-related outcome measures for patients
based on differences in test scores. While the existing measures do not fully
capture the construct of health literacy, they have provided information
about vulnerable populations. Although the existing body of research is
revealing and suggestive, generalization of results to large populations is
limited. Each study focuses on a specific population, which differs from
others along relevant dimensions such as age, socioeconomic status, eth-
nicity, and primary languages. Also many studies use different measure-
ment tools and in some cases the researchers modified the scoring of these
tools. Better measures are needed if we are to be able to align our under-
standing of the distribution of health literacy with the development of
intervention strategies.
Finding 2-4 While health literacy measures in current use have spurred
research initiatives and yield valuable insights, they are indicators of read-
ing skills (word recognition or reading comprehension and numeracy),
rather than measures of the full range of skills needed for health literacy
(cultural and conceptual knowledge, listening, speaking, numeracy, writing
and reading). Current assessment tools and research findings cannot differ-
entiate among (1) reading ability, (2) lack of background knowledge in
health-related domains, such as biology, (3) lack of familiarity with lan-
guage and types of materials, and (4) cultural differences in approaches to
health and health care. In addition, no current measures of health literacy
include oral communication skills or writing skills and none measure the
health literacy demands on individuals within different health contexts.
NEEDS AND OPPORTUNITIES

Links between socioeconomic status and health outcomes are well es-
tablished (Adler et al., 1999; Berkman and Kawachi, 2000; Pamuk et al.,
1998; Williams, 1990). Socioeconomic status is generally measured by in-
come, educational attainment, and occupation. Epidemiological studies in-
dicate a strong inverse relationship between health and education. Inci-
dence rates of chronic diseases, communicable diseases, and injuries are all

52 HEALTH LITERACY
inversely related to education, as are disease prevention actions (Pamuk et

al., 1998). The pathways by which educational attainment and health out-
comes affect each other have yet to be established (Grossman and Kaestner,
1997). The component parts of educational attainment, such as literacy
skills, also have not yet been examined in full.
Reliable and valid measures of health literacy will enable researchers
to establish and monitor the magnitude of the issue, changes over time, the
links between health literacy and health outcomes, factors that lead to
health literacy, and the effectiveness of health literacy interventions. Ro-
bust health literacy indicators are needed to move this field of inquiry
forward. Although the committee is not in a position to develop such
measures, it has identified some potentially worthwhile directions to move
towards.
The first is conceptual. As noted above, several definitions of health
literacy are in current use. Consensus is needed to develop an operationally
defined construct of health literacy. This can be accomplished through a
national consensus conference, bringing together stakeholders from a wide
array of health contexts and researchers in health, education, and psycho-
metrics to address the issue of developing operational measures of health
literacy at population levels. Such a conference could build on the work of
this committee by adopting the definition recommended here and concen-
trating on the measurement issues identified by the committee.
Conference participants might consider a process similar to that under-
taken for the development of the national and international assessments of
functional literacy, but with a unique focus on health contexts. Such a focus
would build on this report to develop a detailed and consistent theoretical
model delineating health contexts and articulating the inherent demands
and assumptions within each context. Researchers could be charged with
rigorously collecting health-related texts and tasks used in and outside of
health-care settings. These researchers then could conduct a purposive sam-
pling to adequately represent the broad array of health activities in appro-
priate contexts. Numerous text types would have to be represented for each
context area. Both the materials and the tasks associated with them would
have to be carefully calibrated for levels of complexity and difficulty.
Furthermore, such materials and tasks must consider the role of oral
language skills in health literacy. As noted above, oral language skills,
including both speaking and listening comprehension, were not assessed by
national literacy assessments such as the NALS or IALS. Further explora-
tions are needed, in partnership with scholars in health communication,
education, and linguistics, to develop meaningful measures of oral exchange
skills that are so vital to health contexts.
Causal relationships are another area for future exploration. The Na-
tional Institutes of Health (NIH), foundations, and for-profit organizations

that support health research, particularly on health disparities and inequali-

ties, could address the interrelationships between limited health literacy and
cultural and socioeconomic factors by encouraging research to develop and
test causal models. Establishing causality could help identify intervention
points. Factors to be considered in the exploration of causality include the
relationships between and among health literacy, socioeconomic status,
health status, educational achievement, geographic location, and culture.
These relationships should be considered in the design of large population
surveys.
Links between health literacy and health outcomes initially could be
made through data collection of a number of illustrative public health,
medical, and dental indicators. These might include data relevant to immu-
nization, cancer screening, cardiovascular disease prevention, and on-going
measures of physical activity and nutritional practices. Other opportunities
might include measures of tobacco use, substance use, or injury. Of critical
concern would be access to care and insurance status. In addition, moni-
toring mechanisms for literacy-related access barriers and supportive fac-
tors in hospitals, physician practices, pharmacies, and workplaces are
sorely needed.
National government and statistical agencies could incorporate mea-
sures of health literacy into their work on an ongoing basis. This would
include on-going national surveys of adult literacy such as the NAAL,
designed to follow the 1992 NALS. NAAL has broadened the representa-
tion of health tasks and items in the current survey and the results will
include a separate “health literacy score” derived from questions which
assess how well adults apply literacy skills to understand health-related
materials (National Center for Education Statistics, 2003). Health literacy
measures could be incorporated into other ongoing national surveys such as
the Health Interview Survey (HIS), the Medical Expenditure Panel Survey
(MEPS), Medicare Beneficiary Survey (MBS), and the Behavioral Health
Risk Factor Surveillance System (BHRFSS). The status of health literacy can
be gauged, quantified, and monitored at timely intervals with such indica-
tors if they are developed through partnerships with national institutions
charged with ongoing data collection for health, education, and labor.
Simple measures of health literacy that better reflect the entire literacy
skill set in the context of health are needed for use in intervention research
studies. Researchers in a variety of settings would benefit from simple and
unobtrusive measures to explore the links between individuals’ literacy-
related skills and a variety of outcome measures. Further development of
assessments that differentiate between and among measures of basic lit-
eracy, print literacy for health-related texts and purposes, and health lit-
eracy as a whole would provide greater insight into the factors underlying

54 HEALTH LITERACY
limited health literacy. More rigorous work is needed to develop appropri-

ate, reliable, and valid measures.
For current practice in health-care settings, practitioners could consider
the use of informal assessment measures to gauge health literacy. For ex-
ample, this may involve asking such questions as “How do you learn best?”
or “What would help you most as you learn about your illness and how to
take care of yourself? or “What help do you need for taking this medicine
properly?” Health educators could explore where and how people access
health information and the kinds of visual, oral, or printed materials people
are most comfortable and familiar with. Such informal assessment tech-
niques can be coupled with more formal but easy-to-administer literacy
assessment methods to create a health literacy profile and promote more
meaningful exchanges of information (Doak CC et al., 1998; Doak LG et
al., 1996; Meade, 2001).
A variety of evaluation measures can be infused into the dialogue be-
tween patients and care providers. Doak CC et al. (1996) provide a series
of helpful questions that verify understanding of information. For example,
the care provider might ask “Can you tell me in your own words what the
purpose of this medical test is and how you will prepare for it?” to quickly
identify any communication mismatches or misunderstandings and allow
for clarifications. Approaches to limited health literacy that focus on
changes in clinical practices are discussed in detail in Chapter 5. Research
directions would benefit from considering the strengths and weaknesses of
current practice, so that the most reliable and effective approaches can be
identified.
Finding 2-1 Literature from a variety of disciplines is consistent in finding that

there is strong support for the committee’s conclusion that health literacy, as de-
fined in this report, is based on the interaction of individuals’ skills with health
contexts, the health-care system, the education system, and broad social and cul-
tural factors at home, at work, and in the community. The committee concurs that
responsibility for health literacy improvement must be shared by various sectors.
The committee notes that the health system does carry significant but not sole
opportunity and responsibility to improve health literacy.
Finding 2-2 The links between education and health outcomes are strongly es-
tablished. The committee concludes that health literacy may be one pathway ex-
plaining the well-established link between education and health, and warrants fur-
ther exploration.

Finding 2-3 Health literacy, as defined in this report, includes a variety of compo-
nents beyond reading and writing, including numeracy, listening, speaking, and
relies on cultural and conceptual knowledge.
Finding 2-4 While health literacy measures in current use have spurred research
initiatives and yield valuable insights, they are indicators of reading skills (word
recognition or reading comprehension and numeracy), rather than measures of
the full range of skills needed for health literacy (cultural and conceptual knowl-
edge, listening, speaking, numeracy, writing and reading). Current assessment
tools and research findings cannot differentiate among (1) reading ability, (2) lack
of background knowledge in health-related domains, such as biology, (3) lack of
familiarity with language and types of materials, and (4) cultural differences in
approaches to health and health care. In addition, no current measures of health
literacy include oral communication skills or writing skills and none measure the
health-literacy demands on individuals within different health contexts.
Recommendation 2-1 The Department of Health and Human Services and oth-
er government and private funders should support research leading to the devel-
opment of causal models explaining the relationships among health literacy, the
education system, the health system, and relevant social and cultural systems.
Recommendation 2-2 The Department of Health and Human Services and pub-
lic and private funders should support the development, testing, and use of cultur-
ally appropriate new measures of health literacy. Such measures should be devel-
oped for large ongoing population surveys, such as the NAAL Survey, the MEPS,
the BHRFSS, and the MBS, as well as for institutional accreditation and quality
assessment activities such as those carried out by the Joint Commission on Ac-
creditation of Healthcare Organizations and the National Committee for Quality
Assurance. Initially, NIH should convene a national consensus conference to ini-
tiate the development of operational measures of health literacy that would include
contextual measures.
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58 HEALTH LITERACY
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tional Publishers.
Taylor WL. 1953. “Cloze procedure”: A new tool for measuring readability. Journalism
Quarterly. 30: 415–433.
Williams DR. 1990. Socioeconomic differentials in health: A review and redirection. Social
Psychology Quarterly. 53: 81–99.

The Extent and Associations of

Limited Health Literacy
T
his report has already noted that an individuals’ health literacy level
is the product of a complex set of skills and interactions on the part
of the individual, the health-care system, the education system, and
the cultural and societal context. It has also been noted that most individu-
als will encounter health literacy barriers at some point. High educational
attainment may not be sufficient to negotiate medical and technical lan-
guage and meanings. The following chapters discuss in more detail some of
the barriers and potential approaches to health literacy in the various con-
texts. Here, the focus is on the individual, and particularly, on the indi-
vidual who has limited literacy skills. This chapter provides an overview of
how limited health literacy may restrict an individual’s participation in
health contexts and activities. Look at Figure 3-1 on the following page and
put yourself in the shoes of a patient with limited literacy skills. How would
you feel, what would you do, where would you go, to whom would you
turn if this medication is prescribed for you by your doctor? How compli-
ant could you be about taking your medications correctly?
Navigating modern life in America with very limited literacy can be like
trying to find a hotel in another land, armed with a map of the city but
unable to decipher the letters on the street signs. Everyone—not just those
with limited literacy skills—is increasingly faced with difficult and confus-
ing text at work, at home, in institutional settings such as schools, banks,
social service organizations, and within health-care settings. People of all
literacy levels might be able to manage texts that they frequently encounter
59

60 HEALTH LITERACY
Kedai Ubat Sunshine

123 Jalan Main, Los Angeles, CA 90015
Nama Paskit: Mustahak! Sila baca:

John Lin Ubat ini mungkin
menyebabkan cirit birit,
Nama Ubat: loya kagatalan kulit,
Crixivan (empat ratus mg) kekeringan kulit, sakit
kepala, atau sakit perut.
Arahan: Pesakit dinasihatkan
Telan dua biji, tiga kali sehari. supaya minum banyak air
Jangan makan dua jam sebelum untuk mengelakkan
dan satu jam selepas anda makan pembentukan batu
ubat ini. karang.
FIGURE 3-1 Mock-up prescription medication instructions in Bahasa Malaysia,

the written language of Malaysia.
SOURCE: Shinagawa and Foong (2003). Reprinted with permission.
and use for everyday activities, but will often face problems with unfamiliar
types of text. For example, a woman who has never lived near a public
transportation system may find herself unable to interpret a bus schedule.
Directions for operating a particle accelerator, filing income tax returns, or
choosing between health insurance plans may be similarly indecipherable
for most adults, regardless of literacy skills in other contexts.
As discussed in detail in Chapter 2, current measures of health literacy
rely primarily on print in the health context and not on the broad array of
skills needed for true health literacy. However, since skills with the written
word are linked to skills with the spoken word, we can use information
from these measures as a starting point to make reasonable assumptions
about the average health literacy skill level of adults in the United States.
The following section examines the extent of the problem of health literacy,
estimated from existing measures of literacy based on the National Adult
Literacy Survey (NALS) and from assessments of health literacy.
LITERACY IN AMERICA
About 90 million (47 percent) U.S. adults cannot accurately and consis-
tently locate, match, and integrate information from newspapers, advertise-
ments, or forms (Kirsch et al., 1993). These adults can perform a variety of

EXTENT AND ASSOCIATIONS 61
straightforward tasks using printed materials; however, they are unlikely to

perform, with accuracy and consistency, more challenging tasks using long
or dense texts. These findings have been compared to those in 22 industri-
alized nations that participated in the International Adult Literacy Surveys.
The U.S. scores are very similar to those in Canada, higher than those in
England or Ireland, but lower than those in the Scandinavian countries
(Organization for Economic Co-operation and Development and Statistics
Canada, 2000). U.S. and international education and workforce research-
ers note that the average skill levels are barely sufficient for full participa-
tion in the civic and economic sectors of current industrialized societies
(Sum et al., 2002). About 90 million adults have skills that are inadequate
for many needed tasks.
Of the 90 million adults with limited literacy skills, about 42 million
demonstrated skills in NALS Level 1. Of these, a small percentage had such
limited English literacy skills that they were unable to respond to much of
the survey. Most people performing at Level 1 can perform simple and
routine tasks using uncomplicated materials. They can, for example, locate
a single piece of information in a short and simple piece of text. However,
they have trouble with tasks requiring them to locate or match several
pieces of information in moderately complicated texts. Adults performing
at NALS Level 1 can solve simple math problems when the numbers and
the operations are provided but find it difficult to solve the same problems
when they must locate the numbers and the operations in a piece of text
(Kirsch, 2001; Kirsch et al., 1993). A package of over-the-counter pediatric
cold medicine can be used as an example. An adult performing at NALS
Level 1 would likely be able to locate the words child, children, pediatric on
a package of cold medicine for children. However, one would not expect an
adult with NALS Level 1 skills to be able to read a chart in order to identify
“how much . . . syrup is recommended for a child who is 10 years old and
weighs 50 pounds?” What makes this task so much more complex and
difficult is the fact that the structure of the chart is in columns starting with
age, then typical weights associated with age, then dosage by type including
drops, syrup, chewable 80 mg, and chewable 160 mg. The typical reader
would look down the column to find the age of the child and then over the
row to the column for syrup. In very small print outside the chart itself
there is a conditional statement that tells the reader “if child is significantly
under- or overweight, dosage may need to be adjusted accordingly . . . .”
This level task would fall at NALS level 4 or 5 (Rudd et al., 2003).
Of the 90 million adults with limited literacy skills, 50 million adults
nationwide demonstrated skills at NALS Level 2. Those adults who scored
at NALS Level 2 can locate information in moderately complicated text,
make low-level inferences using print materials, and integrate easily identi-
fiable pieces of information. They can solve simple math problems when

62 HEALTH LITERACY
the numbers and operations are found in familiar and uncomplicated mate-
rials. However, adults at Level 2 find it difficult to perform these operations
in difficult text and to perform operations that are complicated by distract-
ing information and complex texts (Morse, 2002). In addition, they will
find the demands of the chart to determine dosage for children’s cold
medicine difficult and, according to studies assessing informed consent
documents, will find the process of informed consent arduous and most
likely not possible.
Most of the adults in NALS Levels 1 and 2 are “literate”; however,
adults in Level 1 are at a severe disadvantage and adults in Level 2 are
disadvantaged, in relation to the demands of twenty-first century life. These
findings have serious implications for the health sectors. Rudd, Kirsch, and
Yamamoto, in a reanalysis of the NALS with a focus on health-related tasks
only, report similar findings (Rudd et al., 2003). The 1992 NALS survey
provides the most recent nationally representative population survey data
on literacy skills of adults in the United States. The committee believes that
levels of American literacy have not improved over the past decade and that
health systems have become more complex. The committee looks forward
to the publication of the National Assessment of Adult Literacy1 (NAAL),
conducted in 2003, which contains health-related literacy tasks. The com-
mittee believes that the NAAL will significantly expand our understanding
of literacy and health literacy in America, and regrets that the data are not
yet available. In addition, a representative sample of American adults is
included in the new international Adult Literacy & Lifeskills Survey (ALL).2
Linked to the NAAL framework, the ALL also contains health-related lit-
eracy tasks. These two surveys have the potential to provide detailed infor-
mation on the extent of limited health literacy in America.
Demographic Associations with Limited Literacy

The largest proportion of American adults with limited literacy are
native-born Caucasian speakers of English. Over half of the people with
NALS Level 1 skills are Caucasians, and about 57 million Caucasian Ameri-
cans have limited literacy skills (NALS Levels 1 and 2) (Kirsch et al., 1993).
However, many groups with higher rates of limited literacy than would be
predicted from population estimates alone were identified by the NALS.
Groups with lower average proficiency scores include those who are poor,
members of ethnic and cultural minorities, those who live in the southern
1For more information, see the NAAL on the National Center for Education Statistics web
site: http://nces.ed.gov/naal/.
2For more information, see ALL on the Educational Testing Service web site: http://www.
ets.org/all.

and western regions of the United States, those with less than a high school
degree or GED, and those who are above the age of 65. It is important to
keep in mind that the NALS was performed only in English, and that clear
differentials for literacy proficiencies can be seen within each population
group on the basis of nativity, education, and access to economic resources
(Kirsch et al., 1993). Table 3-1 displays the percentage of persons overall
and various demographic groups that have NALS Level 1 or 2 literacy
skills, the lowest of five skill levels. Each of these groups is discussed briefly
below in order to highlight those that could potentially benefit from inter-
ventions aimed at improving health literacy.3
Adults over the age of 65 have more limited literacy proficiency than
younger, working adults, according to the NALS data. However, cross-
tabulations indicate that scores for elders vary by education level and access
to financial resources (Kirsch et al., 1993). Hispanics, African Americans,
Pacific Islanders, and Native Americans are also (including Alaska Natives)
over-represented in the numbers of adults with lower literacy proficiency
scores, as indicated by the NALS data (Kirsch et al., 1993). These popula-
tions have increased in number since 1992, when the NALS was performed,
and as a group represent a larger proportion of the U.S. population (U.S.
Census Bureau, 2002). Hispanic and Asian populations in particular have
increased at a greater rate than other U.S. populations. While more recent
literacy data is not yet available, these population increases may represent
an increase in the number of individuals, and the percentage of American
adults, affected by limited health literacy.
Individuals without a high school diploma or GED have lower levels of
literacy proficiency than do those with a high school diploma or education
beyond high school. Nearly all adults who did not finish eighth grade
scored at Level 1 or 2 on the NALS, and 77 percent of these individuals
scored at Level 1. Similarly, among individuals who entered high school but
did not graduate, 81 percent scored at NALS Levels 1 or 2, while only 55
percent of high school graduates scored at those levels (Kirsch et al., 1993).
Since between 400,000 and 500,000 students drop out of high school each
year in the United States (Young, 2002), high school dropouts constitute a
large population likely living without adequate literacy skills.
Overall, more than 70 percent of immigrants tested on the NALS scored
at Levels 1 or 2. The NALS was conducted in English only. Thus the finding
that 25 percent of those scoring in the lowest levels of literacy proficiency
were immigrants to the United States might be expected, since many of
3The information in this section is drawn in part from the background paper “Outside the
Clinician-Patient Relationship: A Call to Action For Health Literacy,” commissioned by the
committee from Barry D. Weiss, M.D. The committee appreciates his contributions. The full
text of the paper can be found in Appendix B.

64 HEALTH LITERACY
TABLE 3-1 Percentage of Adult Population Groups with Literacy Skills

at NALS Levels 1, 2, or 3–4
Percent Respondents at Skill Level
Group Level 1 Level 2 Levels 3–4
All NALS Respondents 22 28 50
Age
16–54 years 15 28 57
55–64 years 28 33 39
65 years and older 49 32 19
Highest Education Level Completed

0–8 years 77 19 4
9–12 years (no high school graduation) 44 37 19
High school diploma/GED (no college study) 18 37 45
Racial/Ethnic Group
White 15 26 59
American Indian/Alaska Native 26 38 36
Asian/Pacific Islander 35 25 40
Black 41 36 23
Hispanic (all groups) 52 26 22
Immigrants to US (various countries of origin)

0–8 years of education prior to arrival in US 60 31 9
9+ years of education prior to arrival in US 44 27 29
Disability
Any mental or emotional condition 48 26 27
Learning disability 59 22 19
Hearing difficulty 35 34 32
Speech disability 54 27 19
Visual difficulty 55 26 19
SOURCE: Unadjusted averages of prose and document literacy scores on the NALS as re-
ported on Tables 1.1A, 1.1B, 1.2A, 1.2B, 1.8, and Figure 1.10 in Kirsch et al. (1993) and on
Table B3.13 in the U.S. Department of Education’s report English Literacy and Language
Minorities in the United States (2001).
those immigrants might have just begun to learn English. In addition, 91

percent of those who did not complete a high school education in their
country of origin scored at the lowest levels of proficiency (see Table 3-1).
A high proportion of people entering the United States from non-English-
speaking nations come from non-industrialized areas of the world in which
there are limited educational opportunities. For example, more than half of
adults who emigrate to the United States from Spanish-speaking countries

had not finished high school in their country of origin (Greenberg et al.,
2001).
Individuals who described themselves as having a physical or mental
condition which prevented them from participating fully in normal activi-
ties tended to score at the lowest levels of proficiency. More than half the
individuals with vision, speech, or learning disabilities performed at NALS
Level 1, as did 48 percent of individuals reporting a mental or emotional
condition. In contrast, 35 percent of individuals reporting a hearing diffi-
culty performed at NALS Level 1.
Approximately 7 of 10 prisoners surveyed by the NALS demonstrated
limited literacy proficiency. Individuals who did not finish school are over-
represented among prison inmates, so in many cases, prisoners represent
the same individuals as those with limited education. NALS investigators
studied nearly 1,150 inmates in 80 federal and state prisons that had been
randomly selected to represent penal institutions across the country (Haig-
ler, 1994).
Several other groups, not specifically studied in the NALS, are also
known to have limited literacy skills. These groups include the persons who
are poor and/or homeless, and military recruits. As discussed in Chapter 2,
social factors affect literacy. Poverty is intertwined with many sociodemo-
graphic variables (Balsa and McGuire, 2001), which, in turn, are associated
with limited literacy. Although the causal relationships are not known,
individuals with limited incomes/access to resources are also more likely
than those with higher incomes/access to resources to have lower literacy
proficiency (Kirsch et al., 1993). Homeless individuals, who may also be
affected by limited literacy and poverty, are the audience recipients of a
variety of state programs developed to enhance literacy skills (Profiles of
State Programs, 1990). Weiss and colleagues used Medicaid enrollment as a
proxy for low income and administered the Instrument for the Diagnosis of
Reading/Instrumento Para Diagnosticar Lectura (IDL) as a measure of lit-
eracy. They found that the majority of low-income individuals involved in
their study had limited reading skills, with the average score at the fifth-
grade level (Weiss et al., 1994). In addition, reading and mathematics skills
of potential military recruits are assessed, and enlistment in the military
requires passing these tests. As many recruits cannot adequately perform
the high school level reading tasks they face in the military, all branches of
the military operate educational programs to increase the literacy skills of
their members (Hegerfeld, 1999).
THE EPIDEMIOLOGY OF LIMITED HEALTH LITERACY

Ninety million people—approximately one-half of our adult popula-
tion—lack the basic literacy skills required for full participation in Ameri-

66 HEALTH LITERACY
can society (Comings et al., 2001; Sum et al., 2002). Basic literacy skills
that can be applied in the context of health are required for health literacy.
As discussed in Chapter 2, there are no assessment tools that fully measure
health literacy, and consequently, no population-based study to date has
directly examined the relationship of literacy to health literacy or of health
literacy, as fully defined, to health. However, correlations between mea-
sures of literacy and measures of reading in the health context such as the
Rapid Estimate of Adult Literacy in Medicine (REALM) and the Short Test
of Functional Health Literacy in Adults (S-TOFHLA) suggest a strong asso-
ciation (Davis et al., 1993; Parker et al., 1995).
Routine health and health-care tasks are often complicated and may
require more literacy skills than those needed to meet the demands of
everyday life. To date, no researcher has fully delineated tasks needed for
the full range of health-related activities nor has anyone fully calibrated the
levels of complexity of the various types of materials used in health con-
texts. However, a review of health literature indicates that research findings
over three decades place a wide variety of assessed materials (based prima-
rily on reading level analyses) at levels that exceed the reading skills of most
high school graduates (Rudd et al., 2000a). The substantial volume of
literature focused on assessments of health-related materials.
Health literacy may also be more reliant on domains of literacy such as
oral (speaking) ability and aural (listening) comprehension that are not
measured by NALS, or the tools currently used to measure health literacy
(discussed in Chapter 2 of this report). Recognizing that basic literacy skills
are required for health literacy, it is reasonable to conclude that individuals
with limited literacy—the 90 million individuals that scored in Levels 1 and
2 of NALS—probably also have limited health literacy. These individuals
likely lack the necessary literacy skills in English needed to effectively ob-
tain and understand much of the health-related information they will inter-
act with at home, at work, or in their communities. Furthermore, limited
health literacy probably affects more than just those with limited literacy.
Individuals with adequate literacy may be affected by the complex literacy
demands of the health-care context, and some individuals may continue to
be affected despite attempts to reduce these demands. These findings, com-
bined with the average NALS scores of U.S. adults, offer a strong argument
that 90 million U.S. adults are severely disadvantaged as they attempt to
function in health-care contexts. The committee considers health literacy to
be a reciprocal function of the health context and the individual. Therefore,
any person, no matter what literacy skills he or she possesses, may well
have limited health literacy once he or she enters complex health-care con-
texts.

I am a nurse with advanced degrees. I read on a college level. Yet, I am a

total health illiterate. How can this be? Well, I’ve been diagnosed with an
unusual type of autoimmune disease that has extended into several other
diseases, one of which—lymphoma—might be fatal. Yet despite my
healthcare background, my ability to understand the written word at a high
grade level, and the many resources at my immediate disposal, I still don’t
understand everything I need to know about my condition. I am writing this
to share with you that it is difficult to piece together all the various compo-
nents of the healthcare system even when you have a knowledgeable support
system and excellent reading ability. I am sharing my personal health situa-
tion with you because even with all the supposed advantages I have as
mentioned above, I still don’t understand my condition and prognosis (Mayer,
2003).
Finding 3-1 About 90 million adults, an estimate based on the 1992

NALS, have literacy skills that test below high school level (NALS Levels 1
and 2). Of these, about 40–44 million (NALS Level 1) have difficulty
finding information in unfamiliar or complex texts such as newspaper ar-
ticles, editorials, medicine labels, forms, or charts. Because the medical and
public health literature indicates that health materials are complex and
often far above high school level, the committee notes that approximately
90 million adults may lack the needed literacy skills to effectively use the
U.S. health system. The majority of these adults are native-born English
speakers. Literacy levels are lower among the elderly, those who have lower
educational levels, those who are poor, minority populations, and groups
with limited English proficiency such as recent immigrants.
Studies of Limited Health Literacy

In this section, we examine the extent of limited health literacy by
examining peer-reviewed studies that provide evidence about the epidemi-
ology, or relative rates, of health literacy skills using currently available
measures in different demographic groups. The conclusions that can be
drawn about health literacy from this research are limited because in most
cases, the studies below identify individuals and groups in which only the
print component of health literacy skills is measured (see Chapter 2).
Studies described in this and the following section represent a sample of
the English-language peer-reviewed studies that measure literacy or use the
REALM or TOFHLA among patients or consumers in a health context. We
note that these measures are, for the most part, assessments of print literacy
in the health context. While these measures all tap into some aspect of
health literacy, the studies do not necessarily use the same standard for

68 HEALTH LITERACY
identifying people with limited skills. It is even the case that any two tests
both claiming to use grade-level scores would not identify the same students
as being below a selected standard because their norming samples most
likely were not the same. Thus the percentages falling below a particular
standard are not directly comparable, but do clearly point to where prob-
lems exist.
Studies were identified by searching the Medline (1966–2003), PsycInfo
(1974–2003), ERIC4 (1963–2003), Sociological Abstracts (1963–2003),
and CINAHL5 (1982–2003) databases through the OVID web gateway for
the indicated years with the following terms as keyword searches: “health
literacy,” “literacy and health,” and “reading and health.” To be included,
the study had to define the health or health-care population cohort, the
literacy measurement tool, and the result of the literacy screening assess-
ment. Additional studies for inclusion were identified through testimony to
the committee by experts in the field (see Appendix A), and the available
bibliographies (Greenberg, 2001; Rudd et al., 2000b; Zobel et al., 2003).
Table 3-2 summarizes identified studies containing information on the
rates of health literacy skills as currently measured among various study
populations. Results are given as percentages of the study participants with
(1) marginal and inadequate health literacy as measured by the TOFHLA
(Parker et al., 1995) or its shorter version (S-TOFHLA; Baker et al., 1999);
or (2) inadequate health literacy as indicated by a score below grade 9 on
the REALM (Davis et al., 1993); or (3) what the authors reported if a
standard measure was not used or if a standard measure was modified.
Table 3-2 also identifies the reported demographic characteristics of the
study participants that were reported to be associated with limited health
literacy.
Studies noted in Table 3-2 document the prevalence of limited health-
literacy skills as measured by the REALM or TOFHLA among patients in
general medical and pediatric clinics; specialty care clinics including those
for asthma, HIV, family planning, obstetrics, and oncology; and commu-
nity-based sites including retirement homes and social service agencies. The
studies show that limited health literacy skills, as measured by current
assessment tools, are common, with significant variations in prevalence
depending on the population sampled (Williams et al., 1998b). In many
cases, however, education was not controlled for, and in some cases differ-
ences based on health literacy assessments were no longer significant when
education was controlled for.
Two large multisite studies of convenience samples that provide esti-
4Educational Resources Information Center.

5Cumulative Index to Nursing and Allied Health Literature.

mates of the prevalence of limited health literacy among users of urban

public hospitals showed variation in prevalence in different geographic
locations. In one study, Williams and colleagues (1995) administered the
TOFHLA in either English or Spanish to patients presenting for acute care
at public hospitals in Atlanta and Los Angeles. The study participants
included 1,892 English speakers from Atlanta or Los Angeles, and 767
Spanish-speaking individuals from Los Angeles only. Almost half (47.4
percent) of the participants in Atlanta had inadequate (34.7 percent) or
marginal (12.7 percent) health literacy scores on the TOFHLA, while in Los
Angeles the rates of limited and marginal health literacy scores were 12.5
percent and 9.5 percent for English speakers and 41.9 percent and 19.8
percent for Spanish speakers. Spanish-speaking participants (tested in Span-
ish) had higher rates of limited health literacy scores than did English-
speaking participants, but these differences were not significant after con-
trolling for years of education.
A more recent multisite study used the S-TOFHLA to assess new enroll-
ees in a Medicare managed care organization in four different geographic
areas: Cleveland, Houston, Tampa, and an area of southern Florida includ-
ing Fort Lauderdale and Miami (Gazmararian et al., 1999b). Participants
were 304 Spanish-speaking and 2,956 English-speaking enrollees. The
prevalence of inadequate and marginal health literacy scores on the S-
TOFHLA among English speakers was 23.5 percent and 10.4 percent,
respectively, while among Spanish speakers prevalence rates were 34.2 per-
cent and 19.7 percent. Results varied by city, with the participants in Cleve-
land showing the highest rate of inadequate health literacy scores among
English speakers at 34.1 percent, and those in Tampa showing the lowest
rate at 16.6 percent. The geographic variation between Spanish-speaking
populations was even more striking; 60 percent of those in Tampa had
inadequate health literacy scores compared with 21.2 percent of those in
Houston. The authors of this study indicated that the geographic variation
between study sites might reflect differences in the interrelated characteris-
tics of race, language, and socioeconomic status. However, when these
variables were controlled for, participants in Cleveland continued to show
the highest rates of limited health literacy scores among English speakers.
Factors mediating geographic differences in skills remain unknown and
warrant further investigation. Increased awareness of these variations could
lead to regionally tailored health literacy interventions.
Studies shown in Table 3-2 suggest that the segments of the U.S. popu-
lation that could be considered at greatest risk for limited health literacy are
those that were reported to have higher rates of limited literacy in the NALS
study and other sources. As with limited literacy reported in the NALS
(Kirsch et al., 1993), limited health literacy as currently measured is more
prevalent among the elderly (Beers et al., 2003; Benson and Forman, 2002;

70 HEALTH LITERACY
TABLE 3-2 The Epidemiology of Health Literacy Skills Among Various

Populations
Participation
Citation Population Rate Study Design Setting
Arnold N = 600 96% Convenience Obstetric clinics,

et al., 2001 Pregnant women sample Louisiana
296 African
American
303 Caucasian
Mean age:
23 years
Beers et al., N = 1805 — — Primary care

2003. 58% African clinics, VA
Published American medical center
Abstract 66% male and university
(Health Literacy hospital
and Patient
Satisfaction
Study)
Bennett N = 212 96% Convenience Prostate clinics

et al., 1998 African sample in Shreveport,
American, 103 LA, and
Mean age: Chicago, IL
70.8 years
Benson and N = 93 52% Convenience Affluent

Forman, 2002 71 women sample retirement
Mean age: community in
83 years Albuquerque,
NM

Reported Demographic
Associations with
Measure Low Health Literacy Prevalence of Literacy Levels
REALM African American race African American women

3rd and below: 9%
4th–6th: 19%
7th–8th: 41%
9th and above: 31%
Caucasian women
3rd and below: 4%
4th–6th: 5%
7th–8th: 26%
9th and above: 66%
REALM African American race REALM

Older age 3rd and below: 2%
Lower education level 4th–6th: 8%
Association with age 7th–8th: 31%
was no longer 9th and above: 59%
significant when
stratified by
education level
Association with race
remained significant
when stratified by
education level
REALM African American race African American men

Geographic location 6th and below: 52.3%
(Louisiana site) Caucasian men:
6th and below: 8.7%
Chicago, IL:
6th and below: 12.3%
Shreveport, LA:
6th and below: 38.1%
TOFHLA Older age 74% or less

Fewer years of on TOFHLA: 30%
education
Continued

72 HEALTH LITERACY
TABLE 3-2 Continued
Participation
Davis et al., N = 396 96% — Pediatric clinic

1994 Parents or other in a public
caretakers hospital,
accompanying Louisiana
pediatric
outpatients
Mean age:
30 years
Fortenberry N = 1035 78% — Clinics,

et al., 2001 Mean age: community-
26.36 based
organizations,
and by street
intercept in 4
sites (CO, IN,
NY, and AL)
Gazmararian N = 3260 39% Cohort Prudential

et al., 1999b New Medicare 3,260 Medicare
enrollees participated Managed
2,956 English out of 8,409 Care Study
speakers, identified 4 sites:
304 Spanish for study Cleveland,
speakers OH,
Age distribution: Houston, TX,
65–69 years: south Florida,
37% and Tampa,
70–74 years: Florida
27.3%
75–79 years:
19.3%
80–84 years:
11%
≥ 85 years:
5.4%

Associations with
REALM and — REALM

WRAT-R 3rd and below: 11%
4th–6th: 16%
7th–8th: 37%
9th and above: 35%
WRAT
Less than 4th: 31%
Less than 7th: 55%
Less than 9th: 73%
REALM — 8th and below: 35%

9th and above: 65%
S-TOFHLA African American race Total

Older age English Spanish
Fewer years of school Inadequate: 23.5% Inadequate: 34.2%
completed Marginal: 10.4% Marginal: 19.7%
History of blue collar Adequate: 66.1% Adequate: 46.1%
occupations
Older age was Cleveland, OH
strongly associated English
with lower health Inadequate: 34.1%
literacy, and this Marginal: 9.9%
association Adequate: 56.0%
remained after
adjusting for years Houston, TX
of school completed English Spanish
and cognitive Inadequate: 28.0% Inadequate: 21.2%
impairment Marginal: 9.4% Marginal: 19.2%
Adequate: 62.6% Adequate: 59.6%
Continued

74 HEALTH LITERACY
TABLE 3-2 Continued
Participation
Gazmararian N = 406 19% Cohort Medicaid managed

et al., 1999a Women enrolled 406 care plan in
in a Medicaid participated Memphis,
managed care out of 2,197 Tennessee
plan identified
Age distribution: for study
19–24 years:
144
25–29 years:
86
≥ 30 years:
175
Kalichman N = 228 — Convenience HIV clinics, AIDS

et al., HIV-infected sample service
2000 adults organizations,
Mean age: social service
39.7 years agencies

et al., 1999 HIV-infected sample service
adults organizations,
Mean age: social service
39.1 years agencies

Associations with
South Florida
English Spanish
Inadequate: 17.3% Inadequate: 34.3%
Marginal: 11.6% Marginal: 20.3%
Tampa, FL
English Spanish
TOFHLA Lower education level 9.6% scored less than 80% on the
(abbreviated Health literacy levels TOFHLA
version) were not
significantly
associated with age,
race, marital status,
employment status,
and poverty status
TOFHLA Fewer years of TOFHLA Scores:

education 0%–20%: 2%
Ethnic/minority status 21%–40%: 2%
Health literacy level 41%–60%: 3%
was not related to 61%–80%: 11%
age, income level, 81%–90%: 23%
gender, or sexual 91%–100%: 59%
orientation
TOFHLA 41% scored below

85% on the TOFHLA
Continued

76 HEALTH LITERACY
TABLE 3-2 Continued
Participation
Kaufman N = 61 — Convenience Public health

et al., 2001 First-time sample clinic,
mothers aged Albuquerque,
18 years or NM
older who had
an infant
between 2 and
12 months
Li et al., N = 55 (REALM 71% Convenience Clinic in the

2000 scores 39 patients sample rural south
available on participated
39) in REALM
Women with testing out
early-stage of 55
breast cancer identified by
retrospective
chart review
Lindau N = 529 91% Prospective Ambulatory

et al., 2002 English-speaking Cohort Obstetrics
patients older and Gynecology
than 18 years clinic and a
Median age: 27 women’s HIV
clinic
Montalto and N = 70 38.% Rural community

Spiegler, 2001 Female: health center
Mean age: 45
Male:
Mean age: 55
Schillinger N = 408 91% Cross-sectional Two primary care

et al., 2002 English- and clinics, public
Spanish- hospital, San
speaking Francisco, CA
type-2 diabetes
patients older
than 30 years
(San Francisco
General
Diabetic
Patients with
Low Health
Literacy Study)

Associations with
REALM — 3rd and below: 0%

4th–6th: 0%
7th–8th: 36%
9th and above: 64%
REALM — 3rd and below: 0%

4th–6th: 12.8%
7th–8th: 12.8%
9th and above: 74.4%
REALM Non-white participant 6th and below: nearly 10%

Those with no or 7th–8th: 33%
public health 9th and above: 61%
insurance
TOFHLA Inadequate: 2.86%

Marginal: 11.43%
Adequate: 85.71%
S-TOFHLA Older age English Spanish

Female gender Inadequate: 27.7% Inadequate: 56.8%
Non-white Marginal: 12.7% Marginal: 14.2%
Spanish-speakers Adequate: 59.6% Adequate: 29.9%
Lower education level
Medicare coverage
Longer time with
diabetes
Continued

78 HEALTH LITERACY
TABLE 3-2 Continued
Participation
Shea et al., N = 2494 — Cohort Urban community-

2003. (Health literacy based practices
Published and patient
abstract satisfaction
study)
Weiss et al., N = 402 75% Cohort University Family

1994 Medicaid Care, a health
enrollees, care organization
21.6% Male, in Tucson, AZ
78.4% Female
45.8%
Hispanic
42.8%
Caucasian
5.5%
African
American
Mean age: 49.0
Williams N = 483 ED = 79% Cohort ED and AC at

et al., 273 from AC = 90% urban public
1998a emergency hospital,
department Atlanta, GA
(ED)
210 from
asthma clinic
(AC)
ED
Mean age: 37
AC
Mean age: 47
Williams N = 516 94% (LA) Cohort General medical

et al., Patients with 86% clinics of two
1998b hypertension (Atlanta) urban public
(n = 402) and hospitals
patients with (Atlanta and
diabetes Los Angeles)
(n = 114)

Associations with
S-TOFHLA — Inadequate: 25%

Marginal: 11%
Adequate: 65%
Instrument for Spanish-speaking 0: 8.7%

the 1st: 4.7%
Diagnosis 2nd: 5.1%
of Reading/ 3rd: 5.6%
Instrumento 4th: 4.2%
Para 5th: 5.2%
Diagnosticar 6th: 13.7%
Lecturas 7th: 14.2%
(IDL) 8th and above: 38.6%
REALM Older age 3rd and below: 13%

4th–6th: 27%
7th–8th: 33%
9th and above: 27%
TOFHLA Older age Diabetes patients* Hypertension

Spanish-speaking Inadequate: 44% patients*
Marginal: 11% Inadequate: 49%
Adequate: 45% Marginal: 12%
Adequate: 39%
*results include both Spanish- and English-
speaking individuals
Continued

80 HEALTH LITERACY
TABLE 3-2 Continued
Participation
Williams N = 2,659 77.% Cohort Two urban public

et al., 1995 Patients Atlanta, hospitals in
presenting for 84% Los Atlanta and
acute care, Angeles Los Angeles
1892 English
speakers,
767 Spanish
speakers
(Literacy in
Health Care
study)
REALM: 4 levels: (1st–3rd, 4th–6th, 7th–8th, 9th and above).

TOFHLA: Inadequate health literacy (score 0–59), marginal health literacy (score 60–74),
adequate health literacy (score 75–100).
Gazmararian et al., 1999b; Schillinger et al., 2002; Williams et al., 1995,

1998a, b). Limited literacy and health literacy as measured by these studies
in older adults is an important problem. Older individuals generate high
health-care costs (Berk and Monheit, 2001). High health-care costs, in turn,
are associated with limited literacy (see below for a detailed discussion).
While older individuals have some of the highest rates of limited health
literacy scores and limited functional literacy scores, they also have some of
the most demanding health-care needs. Limited health literacy in older
adults may contribute to a situation in which those most in need of health
care may be those least able to access and benefit from the care.
Studies with current health literacy measures have reported that demo-
graphic associations with limited health literacy include racial or ethnic
minority status (Arnold et al., 2001; Beers et al., 2003; Bennett et al., 1998;
Gazmararian et al., 1999b; Kalichman et al., 2000; Lindau et al., 2002;
Schillinger et al., 2002), fewer years of schooling or lower education level
(Beers et al., 2003; Benson and Forman, 2002; Gazmararian et al., 1999a, b;
Kalichman et al., 2000; Schillinger et al., 2002), and being a Spanish-
speaker (tested in Spanish; Weiss et al., 1994). Notably, these demographic
groups identified by several assessments conducted in different settings are
the same demographic groups identified by the NALS, discussed earlier.
However, none of these studies have involved a sufficiently large random
sample of adults that would allow us to extrapolate these findings to other
populations.

Associations with
TOFHLA Age 60 years or above Los Angeles

Spanish-speaking English Spanish
Adequate: 78% Adequate: 38.3%
Atlanta
Inadequate: 34.7%
Marginal: 12.7%
Adequate: 52.6%
S-TOFHLA: Inadequate health literacy (score 0–53), marginal health literacy (score 54–66),
adequate health literacy (67–100).
IDL: Grade level scores from 0 to 8, 0 indicating failure at grade level 1, 8 indicating read-
ing comprehension at or above the 8th grade level.
THE ASSOCIATIONS OF LIMITED HEALTH LITERACY

Research study findings linking the presence of limited health literacy
as currently measured to poor health are accumulating, although the causal
relationship between health literacy and health is unknown. This research
can be thought of as addressing two types of costs associated with limited
health literacy: economic costs to society and the health-care system, and
costs in terms of the human burden of disease. This section will review both
peer-reviewed and new evidence of the association of limited health literacy
as measured by the REALM or TOFHLA with health outcomes, health-
related knowledge and behaviors, and economic costs. The personal costs
of limited health literacy also bear consideration. Many adults overestimate
their knowledge and understanding of health information, including in-
structions for their own care (Davis et al., 1996; Doak et al., 1996). Others
may be all too aware of their difficulty understanding health information.
Limited health literacy may also take a psychological toll; one study found
that those with limited health literacy as measured by the S-TOFHLA re-
ported a sense of shame about their skill level (Parikh et al., 1996).
Finding 3-2 On the basis of limited studies, public testimony, and

committee members’ experience the committee concludes that the shame
and stigma associated with limited literacy skills are major barriers to

82 HEALTH LITERACY
Associations with Health Knowledge, Behavior, and Outcomes

Individuals with inadequate health literacy as currently measured re-
port less knowledge about their medical conditions and treatment, worse
health status, less understanding and use of preventive services, and a higher
rate of hospitalization than those with marginal or adequate health literacy
(for review, see Parker et al., 2003). Table 3-3 displays a sampling of
studies that provide evidence of health-related associations with health
literacy as measured by currently available assessments of print literacy in
the health context. These studies were identified using the same methodol-
ogy as described in the previous section.
A number of researchers examined relationships between patients’
scores on the REALM or TOFHLA, knowledge of illnesses, and chronic
condition management. Studies included in Table 3-3 demonstrate that
hypertension, diabetes, asthma, and HIV/AIDS patients with lower scores
have less knowledge of their chronic illness and its management than those
with higher scores (Kalichman et al., 2000; Schillinger et al., 2002; Will-
iams et al., 1998a, b). Examination of health literacy scores and health-care
management found that patients with limited health literacy as determined
by current measures have a decreased ability to share in decision making
about prostate cancer treatment (Kim et al., 2001), lower adherence to
anticoagulation therapy (Lasater, 2003; Win and Schillinger, 2003), and
worse glycemic control (Arnold et al., 2001; Kalichman and Rompa, 2000;
Schillinger et al., 2002; Williams et al., 1998a, b).
As noted in Table 3-3, several studies have demonstrated a relationship
between hospitalization rates and limited health literacy as measured by the
TOFHLA or REALM (e.g., Baker et al., 1997, 2002a). For example, Gor-
don and colleagues (2002) demonstrated that although rheumatoid arthri-
tis patients of differing literacy levels had similar levels of rheumatoid
arthritis-related dysfunction, those scoring lower on the REALM had sig-
nificantly more hospital visits in the previous 12 months than age- and sex-
matched controls with higher scores. Arozullah and colleagues (2002) in-
vestigated the relationships between health literacy level, the preventability
of hospital admissions, and the causes of preventable hospital admissions.
Patients scoring at or below the third-grade level on the REALM had an
increased risk (odds ratio (OR) = 8.5) of preventable admission as com-
pared to those scoring at the ninth-grade level and above, while patients
with fourth- to eighth-grade literacy had an OR for preventability of 2.5.
Furthermore, preventable admissions among patients with literacy levels at
or below sixth grade were more likely than preventable admissions among
those with above sixth-grade literacy to be related to system-level factors
such as the availability of outpatient diagnostic care.
Health literacy level has also been linked to self-reported health status.
Baker and colleagues found that among both individuals at a public hospi-

tal (1997) and in a Medicare managed care health plan (2002a), those with
inadequate health literacy as determined by the TOFHLA were significantly
more likely than patients with adequate health literacy scores to report their
health as poor.
Health literacy levels may influence health status by affecting care-
seeking behavior. A study by Bennett and colleagues (1998) indicated that
individuals with lower health literacy scores on the REALM may enter the
health-care system when they are sicker than those with higher health
literacy scores; among men with prostate cancer, those scoring lower on the
REALM were more likely to be initially diagnosed at a more advanced
stage of disease than those with higher health literacy. However, this differ-
ence was not statistically significant after adjustments for race, age, and
location or care. Several studies have showed that individuals with lower
health literacy scores are less likely than those with higher health literacy
scores to make use of preventive health-care services. Scott and colleagues
(2002) found that, among Medicare managed care enrollees, those with
inadequate health literacy, as measured by the S-TOFHLA, used preventive
health services (including influenza and pneumococcal vaccinations, mam-
mogram, and Pap smear) less than enrollees with higher health literacy.
Similarly, Fortenberry and colleagues (2001) administered the REALM test
to 1,035 people in four sites across the country, and found that higher
REALM scores were independently associated with gonorrhea testing in the
previous year. In contrast, Moon and colleagues (1998) found no relation-
ship between parental literacy levels, as measured by the REALM, and use
of preventive health services for pediatric patients.
Finding 3-3 Adults with limited health literacy, as measured by read-

ing and numeracy skills, have less knowledge of disease management and of
health-promoting behaviors, report poorer health status, and are less likely
to use preventive services.
While research in developing countries rarely examines health literacy,

a number of studies have examined the association between literacy or
reading levels and health outcomes. A Bolivian study found that children of
individuals participating in health, literacy, or small business financing
programs offered through an international non-governmental organization
were at less risk of becoming malnourished than children from comparison
communities (Gonzales et al., 1999). A World Bank study of the associa-
tion between maternal educational attainment and child health in Morocco
found that the mother’s health knowledge was associated with improved
child health and nutrition (Glewwe, 1999). In contrast, a 10-year study of
factors influencing infant and child health in Pakistan showed notable im-
provements in indicators of health, including a 69 percent increase in vacci-

84 HEALTH LITERACY
TABLE 3-3 Health-Related Associations of Health Literacy Skills

Participation
Arnold N = 600 96% Convenience Obstetric clinics,

et al., 2001 Pregnant women sample Louisiana
296 African
American
303 Caucasian
Mean age: 23
Baker et al., N = 2,787 37% Cohort Prudential

2002b Medicare 2,787 of 7,471 Medicare
enrollees selected managed care
354 African enrollees (4 sites)
American
2,343 Caucasian
Mean age: 73
Baker et al., N = 3,260 44% Prospective Prudential

2002a Medicare 3,260 of 7,471 cohort Medicare
enrollees selected managed care
2,956 English enrollees (4 sites)
speakers
304 Spanish
speakers
Baker et al., N = 979 — Prospective Large public

1998 (Literacy in cohort hospital
Health Care emergency
Study) department;
Atlanta

Data Collection Method Health-Related Outcome Associations
REALM Participants scoring lower on the REALM

Structured interview had less knowledge about the effects of
Urine cotinine levels smoking and less concern about the
Self-report of smoking practices health effects of smoking on their baby
than those with higher scores.
REALM scores were not related to smoking
practices even when race, age, and living
with a smoker were controlled.
S-TOFHLA Health literacy was linearly related to the

Mini-Mental State Examination total MMSE score across the entire range
(MMSE) of S-TOFHLA scores.
Self-report
S-TOFHLA Participants with inadequate and marginal

Structured interview health literacy reported worse health
MMSE status. They were also significantly more
Geriatric Depression Scale likely to have been hospitalized than
Short Form-12 Health Survey (SF-12), those with adequate health literacy. This
a measure of self-rated physical and relationship remained after adjusting for
mental health demographics, income, schooling,
Managed care organization claims cognitive function, and social support.
Spanish-speaking individuals at all literacy
levels had a lower risk of admission than
English speakers.
TOFHLA Patients with inadequate literacy were

Structured interview significantly more likely to be
Grady Memorial Hospital information hospitalized one or more times than those
system with marginal or adequate literacy. This
association remained after adjusting for
age, gender, race, self-reported health,
socioeconomic status, and health
insurance.
Continued

86 HEALTH LITERACY
TABLE 3-3 Continued

Participation
Baker et al., N = 2,659 81% Prospective Two large public

1997 979 Atlanta cohort hospitals:
Los Angeles Atlanta and
913 English Los Angeles
speakers
767 Spanish
speakers
(Literacy in
Health Care
Study)
Bennett N = 212 96% Convenience Prostate clinics in

et al., 1998 Low-income men sample Shreveport, LA
109 African and Chicago, IL
American
103 Caucasian
Mean age:
70.8
Fortenberry N = 1,035 78% Convenience Clinics,

et al., 2001 Mean age: 26 sample community-
based
organizations,
and by street
intercept (4
states: CO, IN,
NY, and AL)

TOFHLA Participants with inadequate health literacy

Interview were significantly more likely than
participants with adequate health literacy
to report poor health. This association
remained after controlling for age,
gender, race, and socioeconomic
indicators.
No relationship existed between literacy
level and ambulatory care use after
adjusting for age, health status, and
economic indicators. At one of the study
sites (Atlanta, GA), patients with
inadequate literacy were more likely to
have been hospitalized in the year
preceding the study, and this relationship
remained after controlling for age,
gender, race, socioeconomic indicators,
and self-reported health.
REALM Participants with literacy levels below the

Medical record review sixth grade were significantly more likely
Pathology reports to present with Stage D cancer than those
with higher literacy levels.
REALM After adjustment for missing REALM data,

Structured interview a REALM score of ninth grade or higher
was independently associated with
gonorrhea testing in the previous year.
(Other independent predictors of testing
were past suspicion of gonorrhea, self-
inspection for gonorrhea, self-efficacy for
care seeking, and younger age).
Participants scoring lower on the REALM
rated themselves more likely to acquire
gonorrhea in the next 12 months than
those with higher REALM scores.
Continued

88 HEALTH LITERACY
TABLE 3-3 Continued

Participation
Gazmararian N = 406 19% Cohort Medicaid managed

et al., 1999a Women enrolled 2,197 care, Memphis,
in health plan identified for Tennessee
Age distribution: study: 1,061
19–24: 144 not located.
25–29: 86
≥ 30: 175
Gazmararian N = 3,260 44% Cohort Prudential

et al., 2000 New Medicare Medicare
enrollees managed care
2,956 English (4 sites)
speakers
304 Spanish
speakers
76% Caucasian
Gordon N = 123 96.8% Cross-sectional Arthritis clinic

et al., 2002 Patients with
rheumatoid
arthritis
Median age:
56 years
Range:
19–77 years

S-TOFHLA Higher rates of low health literacy were

Interview observed among participants who had
ever used an intrauterine device,
douching, rhythm, or levonorgestrel
implants as methods of birth control than
women who had used other methods of
birth control.
Compared with women with good reading
skills, women with low reading skills
were 2.2 times (95% confidence interval
[CI] 1.1, 4.4) more likely to want to
know more about birth control methods
and 4.4 times (95% CI 2.2, 9.0) more
likely to have incorrect knowledge about
when they were most likely to get
pregnant. These relationships were
significant after controlling for age, race,
and marital status.
There was no relationship between health
literacy levels and either pregnancy
intendedness or current use of
contraception.
S-TOFHLA Participants with inadequate health literacy

Geriatric Depression Scale skills were significantly more likely to
Interview report depressive symptoms than those
with adequate health literacy skills.
However, this association was no longer
significant after controlling for health
status.
REALM REALM scores not related to disease

Interview duration, numbers of joint replacements,
Case record review or number of previous disease-modifying
Health Assessment Questionnaire antirheumatic drugs.
Hospital Anxiety and Depression Scale “Illiterate” patients had three times as
Carstairs Index of social deprivation many hospital visits as controls in the
previous 12 months.
Continued

90 HEALTH LITERACY
TABLE 3-3 Continued

Participation
Guerra and N = 1,301 49% Convenience Four community-

Shea, 2003. Patients over 18 sample and one
Published years of age university-based
Abstract insured by primary care
Medicaid or practice
Medicare
Mean age: 42.2
(Health Literacy
and Patient
Satisfaction
Study)
Kalichman N = 228 Convenience HIV clinics, AIDS

et al., 2000a HIV-positive sample service
Mean age: 40 social service
agencies

TOFHLA Inadequate health literacy was significantly

Charlson Comorbidity Index associated with greater comorbidity
SF-12 Questionnaire burden, and this association remained
after adjusting for confounders.
Inadequate functional health literacy was
not related to health status after adjusting
for confounders.
TOFHLA Participants with lower health literacy were

Questionnaire or interview significantly less likely than those with
higher health literacy: to report an
undetectable HIV viral load, to indicate
that they understand the meaning of viral
load and CD4 cell counts, to state that
their doctors ask their opinions about
treatment, and to state that their doctors
explain things to them so they
understand.
Participants with lower health literacy were
significantly more likely than those with
higher health literacy: to visit a doctor at
least once per month, to believe that HIV
medications reduce HIV-transmission
risk, to believe that it is safe to have sex
if an HIV+ person has an undetectable
viral load, to state that new HIV
treatments make it easier to relax about
unsafe sex, and to state that they practice
more unsafe sex because of new
treatments.
Health literacy level was not related to CD4
cell counts, amount of time since learning
of HIV status, number of HIV-related
symptoms, having diagnosed AIDS-related
conditions, use of anti-HIV therapies, and
some measures of treatment optimism.
Continued

92 HEALTH LITERACY
TABLE 3-3 Continued

Participation

and Rompa, HIV-positive sample service
2000 adults organizations,
Mean age: 40 social service
agencies

et al., 1999 HIV-positive sample service
Mean age: 39.1 social service
agencies
Kaufman N = 61 — Convenience Public health

et al., 2001 First-time sample clinic
mothers aged
18 years or
older who
spoke English
as their first
language and
had an infant
between 2 and
12 months

Reading comprehension section of HIV-infected participants with lower health

TOFHLA (lower literacy defined as literacy had lower CD4 cell counts,
scoring at or below 80%, higher higher viral loads, were less likely to be
literacy as scoring above 80%) taking antiretroviral medications,
Questionnaire or interview reported a greater number of
hospitalizations, and reported poorer
health than those with higher health
literacy. After adjusting for years of
formal education, lower health literacy
was associated with poorer knowledge of
one’s HIV-related health status, poorer
AIDS-related disease and treatment
knowledge, and more negative health-care
perceptions and experiences.
Adapted reading comprehension Participants with fewer years of education

section of TOFHLA (lower literacy and lower health literacy were
defined as scoring 85% or below, significantly more likely to be non-
higher literacy as scoring above adherent in the past 2 days than those
85%) with higher health literacy, and this
Interview association remained after controlling for
Questionnaire/survey age, ethnicity, income, HIV symptoms,
substance abuse, social support,
emotional distress, and attitudes toward
primary care providers. Persons of low
literacy were more likely to miss
treatment doses because of confusion,
depression, and desire to cleanse their
body than were participants with higher
health literacy.
REALM (higher health literacy defined Participants with higher health literacy were
as high school level or above, and significantly more likely than those with
lower health literacy as seventh- lower health literacy to initiate and
eighth-grade level) sustain breastfeeding during the first 2
Survey months.
Continued

94 HEALTH LITERACY
TABLE 3-3 Continued

Participation
Lindau N = 529 91% Prospective Ambulatory

et al., 2002 English-speaking cohort OBGYN clinic
patients older and a women’s
than 18 years HIV clinic
Median age: 27
58% African-
American
18% Hispanic
Moon et al., N = 543 85.8% Prospective Pediatric acute

1998 Parents cohort care clinic
accompanying
children to
clinic
Mean age: 32
Parikh et al., N = 202 65% Cohort Emergency

1996 Patients from department and
Literacy in walk-in clinic,
Health Care Atlanta, GA
Study
Mean age: 41
92% African
American

REALM Health literacy level was the only factor

Interview independently associated with knowledge
Chart review related to cervical cancer screening. This
Physician survey association remained after controlling for
education, employment, ethnicity,
insurance, and age.
Participants with inadequate and marginal
health literacy were significantly more
likely than those with adequate health
literacy to: state that they would seek
care for an illness in an emergency
department or acute care facility (11%
vs. 3%); not seek medical care if
informed of an abnormal Pap test (30%
vs. 19%).
REALM REALM score significantly correlated with

Interview parental perception of how sick the child
was. No relationship between REALM
score and use of preventive services,
comprehension of diagnosis, medication
name and instructions, or ability to
obtain and administer prescribed
medicines.
TOFHLA 67.4% of participants with inadequate or

Survey marginal health literacy stated that they
Interview had trouble reading and understanding
what they read. 39.7% of these
participants acknowledged they have
shame about their reading difficulty. Of
the participants who had low functional
health literacy and admitted having
trouble reading, 67.2% had never told
their spouses, and 53.4% had never told
their children of their difficulties reading.
Nineteen percent had never disclosed
their difficulty reading to anyone.
Continued

96 HEALTH LITERACY
TABLE 3-3 Continued

Participation
Schillinger N = 74 71% Cohort 2 primary care

et al., 2003 English-speaking clinics, public
patients with hospital, San
diabetes Francisco, CA
mellitus and
low functional
health literacy
Mean age: 64
85% non-white
(San Francisco
General
Diabetic
Patients with
Low Health
Literacy Study)
Schillinger N = 408 91% Cross-sectional Two primary care

et al., 2002 English- and clinics, public
Spanish- hospital, San
speaking Francisco, CA
type-2 diabetes
patients older
than 30 years
(San Francisco
General
Diabetic
Patients with
Low Health
Literacy Study)
Scott et al., N = 2,722 36% Cohort Prudential

2002 New Medicare Medicare
enrollees managed care
between 65 (4 sites)
and 80 years Cleveland,
old Houston,
Mean age: 71 Tampa, or
South Florida

S-TOFHLA After a multivariate logistic regression, 2

Audiotaped patient-physician variables were independently associated
interaction with good glycemic control among a
group of diabetes patients with low
health literacy: higher health literacy
levels, and physicians’ use of an
interactive communication strategy.
S-TOFHLA After adjusting for patients’

Diabetes care profile social support sociodemographic characteristics,
scale depressive symptoms, social support,
Short form of the Center for treatment regimen, and years with
Epidemiologic Studies Depression diabetes, three variables were
Scale independently associated with HbA1c
Interview level: health literacy level, insurance
Hospital database status, and treatment regimen.
Patients with inadequate health literacy
were less likely than those with adequate
health literacy to achieve tight glycemic
control and were more likely to have to
report having retinopathy.
S-TOFHLA Inadequate health literacy was

Interview independently associated with lower use
of preventive health services including
receiving the influenza and pneumococcal
vaccinations, mammogram, or a Pap
smear. This association remained
significant after adjusting for
demographics, years of school completed,
income, number of physician visits, and
health status.
Continued

98 HEALTH LITERACY
TABLE 3-3 Continued

Participation
Shea et al., N = 2,494 — Cohort Urban

2003 62% Hispanic community-
Published 78% female based practices
Abstract 50% younger
than 40
(Health Literacy
and Patient
Satisfaction
Study)
Weiss et al., N = 402 75% Cohort University Family

1994 Adult Medicaid Care, a health-
enrollees care organization
78.% Female Tucson, AZ
46% Hispanic
43% Caucasian
Mean age: 49
Williams
et al., 1998a N = 483 90% Cohort Emergency
273 from department and
emergency asthma clinic at
department urban public
Mean age: 37 hospital,
210 from Atlanta, GA
asthma clinic
Mean age: 47
Williams
et al., 1998b N = 516 94% (Los Cohort Two urban public
402 patients Angeles) hospitals in Los
with 86% (Atlanta) Angeles and
hypertension Atlanta
and 114
patients with
diabetes

S-TOFHLA Health literacy level was a significant

Interview predictor of reported satisfaction in all
Consumer Assessment of Health Plans subscale and overall satisfaction scores,
Survey (CAHPS) in 3 different and this relationship remained when
formats: written, with supporting controlling for demographic factors and
illustrations, and an automated the type of CAHPS instrument given.
telephone survey
Instrument for the Diagnosis of There was no significant relationship

Reading between literacy and health-care costs.
University Famili Care Records
REALM Reading level was the strongest predictor of

Interview asthma knowledge score in a multivariate
Observation of Metered dose inhaler analysis. Poor MDI technique was found
(MDI) technique in 89% of patients reading at less than
the third-grade level compared with 48%
of patients reading at the high school
level. Reading level was the strongest
predictor of MDI technique in
multivariate regression analyses.
TOFHLA (in either English or Spanish) Participants with inadequate or marginal

Interview functional health literacy and either
hypertension or diabetes had significantly
less knowledge of their disease than those
with adequate functional health literacy.
There were no significant relationships
between health literacy and measures of
outcome (blood pressure, or HbA1c
level).

100 HEALTH LITERACY
nation rates, although the numbers of literate women did not change and
there was a 12 percent increase in the number of literate men. This study
also suggests that health behaviors may improve as a result of changes in
health-care delivery without improvements in individual literacy (Northrop-
Clewes et al., 1998).
Financial Associations of Low Health Literacy

The limited information available suggests that limited health literacy
may be associated with increased consumer, health provider, and the health-
care system costs. Weiss and colleagues (1994) initially found no associa-
tion between literacy skills, as measured by grade-equivalent reading level,
and total 1-year health-care charges in 402 randomly selected Arizona
Medicaid enrollees. The relationship between costs incurred and reading
level as assessed by the IDL in the 72 patients in the original sample who
were not seeking prenatal care was reanalyzed since 330 patients in this
study were receiving prenatal care that had a fixed cost. The health-care
costs of the remaining 72 patients showed greater variation. Consistent
with REALM scoring, which categorizes the lowest reading group as third
grade and under, the authors divided the sample at grade 3. Patients with a
reading level at or below third grade had mean Medicaid charges of
$10,688, while patients who read above the third-grade level had mean
charges of $2,891 (p = 0.025) (Weiss and Palmer, 2004).
Friedland (1998) presented an analysis of the association of literacy
and health-care utilization using data from the Health Care Financing Ad-
ministration,6 the NALS, and the Survey of Income and Program Participa-
tion. This estimate was derived from predicted levels of functional literacy
and estimates of health-care use. Differences in health-care spending were
estimated by comparing health-care utilization by people with a lower
probability of having functional literacy skills to health-care utilization by
people those with a higher probability of having functional literacy skills.
Friedland suggested that the additional health-care resource attributable to
inadequate health literacy (NALS Level 1) in 1996 was $29 billion if inad-
equate health literacy was equivalent to inadequate literacy, and would
have grown to $69 billion if even half of the marginally literate (NALS
Level 2) were also considered not health literate (Friedland, 1998). This
estimate has been cited elsewhere and, while illustrating the depth of the
problem of limited health literacy, does not directly address the issue of
cost.7
6HCFA, now the Centers for Medicare & Medicaid Services.

7The committee thanks Robert Friedland, Ph.D., for his contributions to this section of the
report.

Associations of patient literacy with health-care utilization were exam-

ined by Baker and colleagues (1998, 2002a). Two analyses showed that
limited literacy patients have higher rates of hospitalization that may be
associated with greater resource use. Of 979 patients seen in the emergency
department of Grady Memorial Hospital (Atlanta) in 1994–1995, logistic
regression showed that those with inadequate health literacy, as measured
by the TOFHLA, were more likely to be hospitalized (31.5 percent) than
patients with adequate health literacy (14.9 percent). The OR after adjust-
ing for confounding variables was 1.69. The adjusted relative risk increased
to 3.15 among patients with inadequate literacy who had been hospitalized
in the previous year (Baker et al., 1998). More recently, Baker and col-
leagues (2002a) studied a prospective cohort of 3,260 Medicare managed
care enrollees. Of the 29 percent of these patients hospitalized over a 2-year
period, the risk of admission was inversely related to health literacy as
measured by the S-TOFHLA. The adjusted relative risk of admission was
1.29 for those with inadequate literacy and 1.21 for those with marginal
literacy; however, it should be noted that education was not controlled for
in this study.
Jose, a Bolivian man in his early 30s, stayed after class one night so I could
help him understand a hospital bill. He had been having bad headaches for
some time. Thinking it was his only option for care, he had gone to the
emergency department to get treatment. There he was told the headaches
would clear up if he got glasses. He was charged $300 for this diagnosis
(Singleton, 2002).
For the purpose of this Institute of Medicine report, the committee

commissioned an examination of the expenditure data collected in associa-
tion with the Baker et al. (2002a) study from David Howard, a health
economist at Emory University.8 Using econometric regression techniques,
Howard found that predicted inpatient spending for persons with inad-
equate health literacy, as measured by the S-TOFHLA, was $993 higher
than that of persons with adequate health literacy. This difference fell to
$450 after controlling for health status. It is not clear whether this control
is appropriate as there may be a bidirectional relationship between literacy
and health status. Emergency care costs incurred by individuals with inad-
8The information in this section is drawn from the background paper “The Relationship
Between Health Literacy and Medical Costs,” commissioned by the committee from David H.
Howard, Ph.D. The committee appreciates his contribution. The full text of the paper can be
found in Appendix B of this report.

102 HEALTH LITERACY
Finding 3-1 About 90 million adults, an estimate based on the 1992 NALS, have
literacy skills that test below high school level (NALS Level 1 and 2). Of these,
about 40–44 million (NALS Level 1) have difficulty finding information in unfamiliar
or complex texts such as newspaper articles, editorials, medicine labels, forms, or
charts. Because the medical and public health literature indicates that health ma-
terials are complex and often far above high school level, the committee notes that
approximately 90 million adults may lack the needed literacy skills to effectively
use the U.S. health system. The majority of these adults are native-born English
speakers. Literacy levels are lower among the elderly, those who have lower edu-
cational levels, those who are poor, minority populations, and groups with limited
English proficiency such as recent immigrants.
Finding 3-2 On the basis of limited studies, public testimony, and committee
members’ experience, the committee concludes that the shame and stigma asso-
ciated with limited literacy skills are major barriers to improving health literacy.
equate health literacy scores were higher than in patients with adequate
literacy, while pharmacy expenses were similar in both groups and outpa-
tient expenditures were lower. Although this Medicare managed care sample
is not representative of the U.S. population as a whole, the results are
consistent with previous reports that limited-literacy individuals make
greater use of services designed to treat complications of disease and fewer
services designed to prevent complications (Baker et al., 1998, 2002; Gor-
don et al., 2002; Scott et al., 2002).
These data suggest that patients with limited literacy may interact with
a complex health-care system in ways that interfere with ideal utilization
patterns and therefore could be more expensive. However, since the causal
relationships between literacy and health-care utilization and cost have not
been discovered, it is not possible to establish a valid cost figure for the
impact of limited health literacy. If the magnitudes suggested by Howard
and Friedland approach the actual costs, they clearly underscore the impor-
tance of addressing this risk factor from a financial perspective, in addition
to health outcome implications. More research is needed to expand these
limited results and move to a clearer estimation of these effects.
Finding 3-4 Two recent studies demonstrate a higher rate of hospital-

ization and use of emergency services among patients with limited literacy.
This higher utilization has been associated with higher health-care costs.

Finding 3-3 Adults with limited health literacy, as measured by reading and nu-
meracy skills, have less knowledge of disease management and of health-promot-
ing behaviors, report poorer health status, and are less likely to use preventive
services.
Finding 3-4 Two recent studies demonstrate a higher rate of hospitalization and
use of emergency services among patients with limited literacy. This higher utiliza-
tion has been associated with higher health-care costs.
Recommendation 3-1 Given the compelling evidence noted above, funding for
health-literacy research is urgently needed. The Department of Health and Human
Services, especially the National Institutes of Health, the Agency for Healthcare
Research and Quality, the Health Resources and Services Administrations, and
the Centers for Disease Control and Prevention; the Department of Defense; the
Veterans Administration; and other public and private funding agencies should
support multidisciplinary research on the extent, associations, and consequences
of limited health literacy, including studies on health service utilization and expen-
ditures.
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Culture and Society
Escorted by his teenage granddaughter, an elderly old Navajo grandfather

was taken to the internal medicine clinic for an infection in his right leg. The
granddaughter was fluent in English but had very limited Navajo speaking
skills. Speaking in English, the doctor informed the man that the infection in
his leg would get worse if he did not take his medication as prescribed. The
granddaughter could not translate the scientific concept of infection into
Navajo language. The doctor asked one of the nurses for help, and although
the she tried as much as she could, she also was unsuccessful. The old man,
becoming frustrated, just agreed that he understood everything that he had
been told. He told the nurse he wanted to have a traditional ceremony
performed for him within a couple of days, and for her to tell the doctor. The
nurse translated this to the doctor, who restated the importance of taking the
medicines. The grandfather insisted he understood, but in fact because he felt
that he did not understand the physician’s explanation, he decided to go to
a traditional medicine man instead. The medicine man helped him the best
he could, but the grandfather’s leg had to be amputated, which the doctor
ascribed to noncompliance.
O
ur understanding of health literacy gains greater depth and mean-
ing in the context of culture. This is especially important given the
ethnic and linguistic diversity of the U.S. population. In addition
to 211,460,626 Americans of European decent, the 2000 U.S. Census iden-
108

CULTURE AND SOCIETY 109
tified 69,961,280 people from 19 other ethnic and cultural groups living in
America (U.S. Census Bureau, 2000). Many of these diverse American popu-
lations have differing systems of belief about health and illness. Cultural
health beliefs affect how people think and feel about their health and health
problems, when and from whom they seek health care, and how they
respond to recommendations for lifestyle change, health-care interventions,
and treatment adherence.
Cultures also differ in their styles of communication, in the meaning of
words and gestures, and even in what can be discussed regarding the body,
health, and illness. Health literacy requires communication and mutual
understanding between patients and their families and health-care provid-
ers and staff. Culture and health literacy both influence the content and
outcomes of health-care encounters.
A definition of health literacy that does not recognize the potential
effect of cultural differences on the communication and understanding of
health information would miss much of the deeper meaning and purpose of
literacy for people (Nutbeam, 2000). Culture provides a context through
which meaning is gained from information, and provides the purpose by
which people come to understand their health status and comprehend op-
tions for diagnoses and treatments. A conceptual understanding of the
interconnections between culture and literacy through the idea of cultural
literacy can provide insights into the deeper meanings of how diverse popu-
lations in the United States come to know, comprehend, and make in-
formed decisions based on valid data regarding their health.
This intersection between culture and literacy is recognized in the U.S.
Department of Health and Human Services (HHS) National Standards for
Culturally and Linguistically Appropriate Services (CLAS) in Health Care.
The standard states that “health care organizations must make available
easily understood patient-related materials . . . in the languages of com-
monly encountered groups . . .” (HHS, 2001: 11). The standard goes on to
state explicitly that in addition to being culturally responsive, these materi-
als need also be responsive to the literacy levels of patients and consumers.
Issues of culture, language, and learning are interrelated, and to be effec-
tive, health education must be conducted in both culturally and linguisti-
cally appropriate formats to address the increasingly diverse multicultural
and multilingual population (AMA Ad Hoc Committee on Health Literacy,
1999).
Cultural, social, and family influences shape attitudes and beliefs and
therefore influence health literacy. Social determinants of health are well
documented regarding the conditions over which the individual has little or
no control but that affect his or her ability to participate fully in a health-
literate society. Native language, socioeconomic status, gender, race, and
ethnicity along with mass culture as represented by news publishing, adver-

110 HEALTH LITERACY
tising, marketing, and the plethora of health information sources available

through electronic channels are also integral to the social–cultural land-
scape of health literacy.
Traditional and mass culture and society provide a lens through which
individuals perceive the mix of opportunities and underlying values and
assumptions inherent in the health system. Society influences individuals
and collectivities such as families, communities, and professional groups.
Social factors work through social networks as well as through government
programs, legislation, and private-sector markets. They are reflected in and
shaped by the media. They are manifested through access to agency and
organizational programs. A wide variety of social factors produce and
diffuse information or misinformation, shape bias, develop and support
health-promoting or -degrading environments, and provide normative pres-
sures. These influence the actions of individuals, collectivities, and the spe-
cialized groups of public health and care providers and therefore suggest
critical intervention points.
TRADITIONAL CULTURE
Culture is the shared ideas, meanings, and values acquired by individu-
als as members of society. It is socially learned, not genetically transmitted,
and often influences us unconsciously. Human beings learn through social
means—through interactions with others as well as through the products of
culture such as books and television (IOM, 2002). Reliance on tools and
symbolic resources, notably language, is a hallmark of culture. Language is
central to social life and mediates the acquisition of much cultural knowl-
edge. Language “provides the most complex system of the classification of
experience” and is “the most flexible and most powerful tool developed by
humans” (Duranti, 1997: 49 and 47). Differences in languages and under-
lying concepts may lead to problems with health-related communication.
For example, translating the word “chemotherapy” into the Navajo lan-
guage might require pages of text. Since the Navajo language has no word
or concept for chemotherapy, the translation must start with the idea of
cancer, and include what the person might experience as a result of chemo-
therapy. This is further complicated by the fact that many Navajos believe
that if you say something will happen, it will1 (Billie, 2003).
Beyond the differences of language, culture gives significance to health
information and messages. Perceptions and definitions of health and illness,
preferences, language and cultural barriers, care process barriers, and ste-
reotypes are all strongly influenced by culture and can have a great impact
1The committee thanks Alvin Billie for his contributions to this section of the report.

on health literacy and health outcomes. Differing cultural and educational

backgrounds among patients and providers, as well as among those who
create health information and those who use it, contribute to problems with
health literacy. The relationship between culture, patient–provider interac-
tion, and quality of care has been reviewed by Cooper and Roter (2003).
Early work showed that European-American cultural groups used language
differently in discussing symptoms such as pain (Zborowski, 1952; Zola,
1966). These linguistic differences were associated with differences in diag-
noses, irrespective of symptomology. African-American patients frequently
experience shorter physician–patient interactions and less patient-centered
visits than Caucasian patients (Cooper and Roter, 2003; Cooper-Patrick et
al., 1999).
It is crucial to note that culture is not static for individuals or for
societies. This dynamic principle of culture is referred to as “cultural pro-
cesses” when groups are discussed, and “lived experiences” in the case of
individuals. Individuals are shaped by their life experiences and are exposed
to multiple cultures. Their behavior may reflect an amalgam of this “expe-
riential identity” (IOM, 2002). For example, the experiential identity of
immigrants includes their experience with the health systems from their
country of origin as well as their immigrant experience. This experiential
identity will incorporate new experiences with the American health system.
Development of adequate health literacy may be hindered by limited En-
glish skills or outcomes of poorly understood health experiences.
Today’s families and communities consist of people with multiple cul-
tural backgrounds and experiences, who cannot be put into rigid “boxes”
by using racial and ethnic labels that are often resented and are misleading.
Individuals, families, and communities have belief systems, religious and
cultural values, and group identity that serve as powerful filters through
which information is received and processed. These concepts of cultural
processes and lived identities replace more traditional concepts such as
“acculturation” and present measurement challenges to researchers and
health service providers.
Culture, cultural processes, and cross-cultural interventions have been
discussed in-depth in several Institute of Medicine (IOM) reports (IOM,
2002, 2003a) which suggest that ways of learning, beliefs about health and
illness, and patterns of communications contribute to health literacy through
their effect on communication, comprehension, understanding, and deci-
sion-making. Socioeconomic status was found to affect health in the IOM
report Promoting Health: Intervention Strategies from Social and Behav-
ioral Research (IOM, 2000). Behavioral and social factors influence a
person’s susceptibility to disease, especially among individuals of lower
socioeconomic status. The 2000 IOM report identified increased preva-
lence of disease among socio-economically underserved groups and out-

112 HEALTH LITERACY
lined “the need to balance clinical approach to disease with recognized

social and class determinants” (IOM, 2000). Social and behavioral inter-
ventions were further investigated in Speaking of Health (IOM, 2002),
which recognized the link between behavior and disease.
In the following section, we examine the relationships between cultural
processes and health literacy for indications of how to make Americans
more literate about health and illness through health systems that are more
responsive to patient needs, preferences, and perspectives.
Cultural Competence
The skills and knowledge of cultural competence provide a trajectory
towards the interpersonal skills for effective patient care that can be real-
ized only when comprehension, understanding, and meaning are inherent
in the process. Cultural competence has been variously defined by different
organizations.2 Speaking of Health (IOM, 2002) notes the following di-
mensions:
• Cultural awareness: A deliberate, cognitive process in which

health-care providers become appreciative and sensitive to values, beliefs,
lifestyles, practices, and problem-solving strategies of clients’ cultures.
• Cultural knowledge: The process of seeking and obtaining a sound
educational foundation concerning worldviews of various cultures; goal is
to understand clients’ world views, or the way individuals or groups of
people view the universe to form values about their lives and the world
around them.
• Cultural skill: The ability to collect relevant cultural data regard-
ing clients’ health histories and presenting problems, as well as accurately
perform culturally sensitive physical histories.
• Cultural encounter: A process that encourages health-care provid-
ers to engage directly in cross-cultural interactions with clients from cultur-
ally diverse backgrounds (IOM, 2002).
Among these four dimensions of cultural competency, common themes

emerge: ways of thinking, understanding world views, cultural data, and
cross-cultural interactions.
2For example, the HHS CLAS standards define cultural competence as “the capacity to
function effectively as an individual and as an organization within the context of cultural
beliefs, behaviors, and needs presented by consumers and their communities” and the Na-
tional Medical Association defines cultural competence as “the application of cultural knowl-
edge, behaviors, clinical and interpersonal skills that enhances a provider’s effectiveness in
patient care.”

Cultural competence becomes important to health literacy at the point

where language and culture interfere with or support effective communica-
tion. While health literacy efforts are not limited to cross-cultural situa-
tions, and cultural competence efforts are broader than health literacy,
initiatives in both these areas would benefit from coordination with each
other. Cultural competency is sometimes approached through recommen-
dations for culturally and socially sensitive communication. These
approaches must take into consideration the dynamic and ever-changing
nature of culture. As culture is constantly being influenced by lived experi-
ences, so must health literacy approaches that are coordinated with cultural
competence be responsive to cultural change. In meeting the health needs of
diverse peoples, cultural competency is essential for the development of
health literacy.
Language
An ob-gyn resident tells of working with an inner city, Hispanic population.

Alone on service late one night, she struggled to communicate with a couple
who spoke only Spanish in order to learn the pregnant woman’s due date.
Grasping at a word familiar from popular music, she said “navidad,
navidad” over and over again to the puzzled couple. Finally, she located
another resident who spoke Spanish and helped her ask the couple about the
“fecha” (date) the baby was expected. They all had a good laugh over her
puzzling repetition of the Spanish word for “Christmas.”
An important component of cultural competence is linguistic compe-

tence. Many individuals receiving care from the U.S. health-care system
have limited English proficiency (LEP). For individuals whose native lan-
guage is not English, issues of health literacy are compounded by issues of
language and the specialized vocabulary used, both in written and spoken
form, to convey health information. The 2000 census indicates that the
foreign-born population in the United States is 31 million. More than 300
different languages are spoken in the United States, and 47 million citizens
and non-citizens speak a language other than English at home (an increase
from 31.8 million in 1990). English is not the primary language spoken in
the homes of 41 percent of Hispanics, 34 percent of Koreans, 29 percent of
Vietnamese, and 20 percent of Chinese (Collins et al., 2002). Eleven million
individuals indicate that they speak English not well or not at all (U.S.
Census Bureau, 2000). Some of these individuals live in isolation from
English, that is, without personal or social resources to understand English.
The profound effect of primary language on health is widely recog-

114 HEALTH LITERACY
nized. It provided the impetus for an Executive Order on improving access

to services for persons with LEP3 and a subsequent report to Congress. The
effect of primary language on health remains a central concern of the
federal Office of Minority Health Center for Linguistic and Cultural Com-
petence in Health Care, established in 1995 to address the health needs of
populations who speak limited English
Individuals with LEP have widely varying levels of literacy and health
literacy in their primary language. When LEP individuals are health literate
in their primary language, the key is providing language assistance either in
the form of care in their primary language or interpreter services and trans-
lated materials. When LEP individuals are not health literate in their own
language, additional efforts are needed ensure adequate communication.
Some languages do not have a written form or individuals may not be able
to read, and so translation services are of no use in such cases. These
individuals may be unfamiliar with medical terminology in their primary
language and, therefore, linguistically competent services alone will be in-
sufficient to ensure adequate communication. Alternatively, individuals may
be health literate in their own culture, but not in Western medicine’s health
system and style of health care.
Cultural Languages
Cultural context gets transformed into cultural language that influ-
ences three critical determinants of health literacy: comprehension, under-
standing, and decision-making. Different cultural groups mobilize creative
forces to formulate unique cultural languages that must be considered in
culturally competent approaches for implementing interventions to pro-
mote health literacy. Two examples of these innovative cultural languages
can be found in the language of Aboriginal people and in the dreams of
Native American cultures.
In contrast to Westernized people whose language use is dominated by
nouns, Aboriginal people use a language dominated by verbs in deference
to their worldly vision of all existence as energy or spirit that is in constant
transformation (Ross, 1996: 116). A consequence is that there is attention
to the “relationship between things” and less focus on the “characteristic of
things” (in a noun-driven language such as English). This feature of using
“fluidity of verb-phrases” is functional in healing relationships. Thus, a re-
thinking and re-framing of the standard inquiries that drive health assess-
3Executive Order No. 13166. Benefit-Cost Report of Executive Order No. 13166: Improv-
ing Access to Services for Persons with Limited English Proficiency. August 2000.

ments via predominant use of nouns, adjectives, and pronouns is necessary

when working with Aboriginal people during health and illness encounters.
In Native American cultures, dreams function as a cultural language to
communicate realities in everyday life and deal with health and illness. The
significance of this for health care is demonstrated by Lincoln (2003) with
respect to the Navajo Indians in Arizona: “Diagnosticians are called upon
to cure sickness caused by dreams or to prevent sickness predicted by
dreams.” (Lincoln, 2003). For Native American peoples, therefore, dreams
are part of the cultural lexicon that informs health literacy.
The Hmong language has no word for cancer, or even the concept of the
disease. “We’re going to put a fire in you,” is how one inexperienced
interpreter tried to explain radiation treatment to the patient, who as a result,
refused treatment (Morse, 2003).
Language and Meaning in the Context of Health

Frequently, words or their underlying concepts have little or no mean-
ing, or a different meaning, for a person from another culture. This is true
both of specific terminology as well as the essential meaning of health and
illness to different people. For example, instructing a patient to take a
teaspoon of medicine assumes that the patient owns a teaspoon that holds
5 cc of liquid, and identifies it as such. Promoting health literacy requires an
awareness and understanding of these differences in meaning and providing
what is needed to increase the probability of treatment adherence (for
example, a teaspoon with which to measure the medicine, or pre-measured
quantities of medicine).
As noted, recent IOM reports (IOM, 2002, 2003a) urge a broad, more
realistic perspective of culture as fluid processes and lived experiences, in
which communications, relationships, and meaning are central themes rel-
evant to health literacy. Conceptual definitions and proposed relationships
between culture and health literacy as human experiences have yet to be
developed. In-depth theoretical concepts to guide scientific inquiries could
arise from conceptual frameworks on the interface between cultural pro-
cesses, literacy, and health literacy. These frameworks must distinguish
between linguistic and cultural processes, both of which are rooted in the
concept of meaning. For example, research on epilepsy found that both
neurologists and patients use the word “trauma,” but neurologists most
often mean “a physical blow,” while patients and families most often un-
derstand the word to imply “psychological damage.” This confusion is

116 HEALTH LITERACY
exacerbated in Latino patients and families since trauma has the same two
meanings in Spanish, but cultural views of illness more often focus on the
psychological meaning (Long et al., 1992). While specific meaning of the
word trauma may differ between individuals and groups, people will act
upon the meaning they understand.
A 45-year-old Hispanic immigrant, Mr. G., undergoes a job health screen-

ing and is told that his blood pressure is very high and he will not be allowed
to continue work until his blood pressure is controlled. He goes to the local
public hospital and is given a prescription for a Beta-blocker and a diuretic.
The doctor prescribes two medications known to be effective and simple for
adherence because they each are supposed to be taken once a day.
Mr. G. presents to the emergency department one week later with dizziness.
His blood pressure is very low, and Mr. G. says he has been taking the
medicine just like it says to take it on the bottle. The puzzling case is dis-
cussed by multiple practitioners until one that speaks Spanish asks Mr. G.
how many pills he took each day. “22,” Mr. G. replies. The provider ex-
plains to his colleagues that “once” means “11” in Spanish.
Similarly, work on dissonances between medical staff and pregnant

women of Mexican origin in Los Angeles revealed that there is no Spanish
word for the English word “labor.” Medical Spanish uses a construct that
translates labor as “the work of childbirth,” but women use the Spanish
word for pain (“dolor”). More important than the words themselves, there
may be large differences in concept for the process of labor between women
and providers. The women described childbirth as “pain and the baby is
born.” Clinicians, who probably think of childbirth as a longer process
with physiological stages, could not understand the women’s panic when
they were told that it was too soon to be admitted to the hospital (Scrimshaw
and Souza, 1982). Communication goes beyond words to encompass the
meaning behind the words, a meaning that is affected by culture, knowl-
edge, and experience.
It is also important to consider signage in health-care settings and
written materials as well as verbal communications. Recently, a clinic in
Guatemala was observed to have the label “Estomocologia” (which trans-
lates as “Stomachology”). This may make more sense to people there than
“gastro-enterology.” There is a tremendous challenge in finding clear and
acceptable signage for hospitals and clinics. One project, Hablamos Juntos,
funded for ten health-care settings by the Robert Wood Johnson Founda-
tion is currently working on signage, literature, and interpreter qualifica-
tions and training.

Anthropologists Good and Good (1981) write about meaning-centered

clinical practice, and note that groups vary in
• the specificity of their medical complaints

• their style of communication around medical complaints
• the nature of their anxiety about the meaning of symptoms
• their focus on organ systems
• their response to therapeutic strategies
Therefore, human illness has meaning, in both the biological sense and as a
human experience. As a result, clinical practice is inherently interpretive
and practitioners must elicit patients’ requests, elicit and decode patients’
use of language, diagnose disease and illness, and develop plans for manag-
ing problems. This includes the need to elicit explanatory modes of patients
and families, analyze conflict with the biomedical model, and negotiate
alternatives (Good and Good, 1981).
Patient Perspectives and Language

Patients’ varied perspectives, values, beliefs, and behaviors regarding
health and illness are consistently cited as integral to quality care in several
IOM reports (IOM, 2001, 2003a). Because culture is the tapestry of shared
ideas, meanings, and values that underlie of human behaviors, references to
“patient perspectives” in health care necessitate an understanding of cul-
tural processes that can be harnessed to promote health literacy. Thinking
styles influence information processing, and what a person attends to and
retains in memory operates within a context that is frequently culturally
determined. A classic example is the many different words for describing
“snow” in Inuit languages, since qualities of snow are essential to many
aspects of life in these cultures. Other cultural groups have two, one, or no
words for “snow,” depending on whether snow is a central fact of daily life.
Similar examples can be identified in health contexts. People with diverse
cultural experiences may differ on how a fever is defined or described, how
pain is expressed, and how body parts are identified, such as whether there
is a word for “hand” but no words for “fingers,” or whether there is a
different name for each finger. Thus, to be health literate in America means
having the cognitive capacity to comprehend the Western biomedical per-
spective. For a clinician, it means working with patients whose perspectives
are shaped by diverse cultural contexts. Cultural processes and lived expe-
riences contribute to widely different and unpredictable ways people under-
stand concepts and spoken words. Culturally responsive communication is
an active process by which we discover how the other person decoded or
understood the stated messages. Being culturally responsive means discov-

118 HEALTH LITERACY
ering differences in frames of reference—the world views, priorities, values,

and understanding each speaker brings to the encounter—on an individual
basis. It requires the use of skills to seek feedback and to verify the conclu-
sions or assumptions we come to as we communicate with another person.
Being culturally responsive also means developing skills to ensure that our
communication is being received as intended. Learning to develop commu-
nication and interpersonal skills to obtain feedback and verify successful
communication is critical to working competently with others, and contrib-
utes to addressing the problem of health literacy.
Family relations can be a motivating factor in behavior change. The
Latino value of familialismo and its influence on health-care interventions
and behavioral change in individual Hispanic patients is well documented.
Perez-Stable found that the social importance of cigarette smoking was
greater for Latinos than for Caucasians. Latinos were also more concerned
about the effects of smoking on interpersonal relationships. As a result,
they felt more certain that quitting smoking would improve family relation-
ships and provide a better example for their children (Perez-Stable, 1994).
Sabogal and colleagues (1987) note that “to motivate a parent to alter a
high-fat diet or increase the level of physical activity to prevent a future
heart attack, . . . appeal[s] to his or her sense of duty to the children. The
extended family network can similarly be used to persuade patient with or
at risk for cardiovascular disease to adhere to prescribed or recommended
medication, diet and exercise regimens.”
The contributions of culture and language to health literacy are rich
and complex. Potential approaches to issues of culture, language, and health
literacy are discussed in the latter section of this chapter.
Finding 4-1 Culture gives meaning to health communication. Health

literacy must be understood and addressed in the context of culture and
language.
Measures Can Dissociate Culture, Meaning, and Health Literacy

The interface among individuals, cultural processes, layers of cultural
experience, families, communities, health systems, and health-care provid-
ers is extremely complex. That complexity affects health literacy for people
at every level of education and access to care. The challenge is to develop
tools for measuring the health literacy effect of that complexity in order to
assess and improve health literacy in the United States from both patient
and provider perspectives. While strong evidence suggests an association
between cultural diversity and health and illness (e.g., IOM, 2003a), the
relationships between diversity and health literacy have yet to be fully
delineated and investigated. This must begin with meaningful measures of

culture, meaning, and health literacy. These new measures should function
to improve the validity of current approaches and provide new knowledge
about the impact of health literacy on health outcomes in diverse popula-
tions.
MASS CULTURE
Mass culture refers to the institutions, organizations, and individuals
that produce and disseminate health messages to Americans. The quantity,
quality, and lack of quality control over these messages have exploded in
the past 10 years. Hundreds of health organizations across the country
from hospitals to advocacy groups to major government agencies like HHS,
the Centers for Disease Control and Prevention (CDC), the National Li-
brary of Medicine, and the National Institutes of Health (NIH), have cre-
ated elaborate “user-friendly” information sources. These are often elec-
tronically accessible 24 hours a day to provide Americans with up-to-date
health information on the care and prevention of disease. But the informa-
tion sources available to Americans do not stop there. Major advocacy
groups such as AARP and The American Cancer Society, plus many others,
also offer detailed information on health care and disease prevention. These
approaches to providing and accessing information are in their infancy, and
must be evaluated and then modified for maximum effectiveness. When
consumer needs are at the core of information provision, whether via print,
digital media, or intrapersonal communication, the information can be
more accessible. With appropriate attention to the information needs of
health-care consumers, new technologies can offer all segments of society
greater access to health information.
In the private sector, the marketing of pharmaceutical drugs—both
over-the-counter and prescription—is now a part of every American’s
television viewing. The cost of pharmaceuticals promotions rose to $19.1
billion in 2001 (Medvantx, 2003). The industry drug packaging and con-
sumer education programs are another powerful source of health informa-
tion. Radio programs provide regular advice on both modern and herbal
medicines. Products of all kinds make health claims as part of their mar-
keting programs. Indeed, health has become a major consumer motivator
along with sex and price promotions in American marketing.
The news media has also taken health information seriously. Dozens of
major news outlets have health reporters who are increasingly skilled in
interpreting health studies. The Journal of the American Medical Associa-
tion is widely quoted and referenced in news articles in both print and
broadcast media. Finally, the Internet has provided an opportunity for any
individual to make health claims about any product or procedure with little
or no scientific basis. In sum, the American public is now faced with a

120 HEALTH LITERACY
© Reprinted with special permission of King Features Syndicate.
plethora of health information and the arduous task of finding, selecting,

reading, understanding, judging, and following the advice presented by
multiple sources.
How People Obtain and Use Health Information

How do people obtain and use health information? There is no single
reliable answer to this question. While data on health information alone is
not available, responses of the National Adult Literacy Survey (NALS)
participants indicated over half of individuals at each literacy skill level as
measured by the NALS obtain information about current events, public
affairs, and government from family and friends, newspapers and maga-
zines, and radio and television (Kirsch et al., 1993). Between 62 and 69
percent of adults at all NALS literacy skill levels reported obtaining infor-
mation from family and friends. Between 94 and 97 percent of adults at all
NALS skill levels reported using radio or television to obtain information.
Individuals in the lower literacy levels were less likely to use print media as
an information source than were adults in the higher levels. While 69.5
percent of the respondents with NALS Level 1 literacy skills reported get-
ting information from newspapers or magazines, 85.5 percent of adults
with literacy skills at NALS Level 2 skills and 90 percent of those with
literacy skills at or above NALS Level 3 reported obtaining information
from newspapers or magazines.

BOX 4-1
Sources of Health Information Reported in a Gallup Poll
Proportion who reported getting a Proportion who reported a great deal

great deal or moderate amount of or moderate amount of trust and
healthand medical information from confidence inthe following sources of
the following sources: health and medical information:
Doctor 70% Doctors 93%

TV 64% Nurses 83%
Books 56% Books 82%
Newspapers 52% Newspapers 64%
Magazines 51% Magazines 62%
Nurse 49% Internet 62%
Internet 37% TV 59%
SOURCE: Gallup Organization (2002).
The National Cancer Institute is presently conducting the Health Infor-

mation National Trends Survey (HINTS), one of the nation’s first national
surveys of health information sources.4 HINTS is designed to provide data
regarding pattern of information use and opportunities to inform Ameri-
cans about cancer; however, survey data is not yet available. In a Gallup
Organization poll of 1,004 adults nationwide, several sources of informa-
tion were cited as “a great deal” or “moderate” sources of health informa-
tion (Gallup Organization, 2002). These sources are shown in Box 4-1.
Confidence levels remain highest about information obtained from doctors
and nurses, but confidence levels (great deal or moderate confidence) from
other sources are also fairly high.
A September 2001 survey called Sex Matters looked at women’s knowl-
edge of sex differences in health (Benenson Strategy Group, 2001). Findings
from this survey, based on telephone interviews of 962 women, indicate
that 44 percent of adult women who said they have a doctor they see
regularly for basic health care indicated that their doctor is the major
source of information. However, when provided with specific information,
only 19 percent said they had heard it from a doctor or nurse, as shown in
Box 4-2.
4For more information, please see http://dccps.nci.nih.gov/hcirb/hints.html.

122 HEALTH LITERACY
BOX 4-2
Selected Findings from Sex Matters
Which of the following Have you ever heard this To the best of your
would you say you use information before: recollection, where did
most often as a source In addition to the typical you hear this informa-
of information about chest pain associated with tion? (asked only of
health for you: a heart attack, women may the 55% who said they
suffer from subtle symptoms had heard it)
such as indigestion,
abdominal or mid-back
pain, nausea or vomiting?
Doctor 44% Yes 55% Newspaper/TV 25%

Magazines 15% No 44% Magazines 22%
Newspapers/TV 14% Don’t know 1% Doctor 17%
Friends/family 14% Friends/family 15%
Internet 7% Don’t know 10%
Nurses 4% Medical text 7%
Don’t know 2% Nurses 2%
Internet 1%
SOURCE: Benenson Strategy Group (2001).
To understand the full impact of health literacy on America’s health

system, we need to understand a wide array of information sources, infor-
mation needs, information contexts, and communication complexity.
Complexity of Materials
Many materials developed to provide health information fail to take
into account the needs of the audiences for these materials. Rudd and
colleagues (2000) reviewed studies of patient information materials, and
found that disparities between the readability of education materials and
patient reading level occurred in ambulatory care settings (Cooley et al.,
1995; Davis et al., 1990), substance abuse treatment centers (Davis et al.,
1993), and pediatric care settings (Davis et al., 1994). Similar findings are
reported for patients with diabetes (Hosey et al., 1990), arthritis (Hill,
1997), and lupus (Hearth-Holmes et al., 1997). These studies found that
the reading levels of groups of patients with these chronic diseases fell
between grade levels 6 and 10, while the readability of the materials de-
signed for them fell between grade levels 7 and 13.

Rudd and colleagues (2000) also showed that several studies examined
patient education materials designed for specific ethnic groups. A substan-
tial number of studies report on both readability and comprehension assess-
ments of these documents, deeming most of them inappropriate (Austin et
al., 1995; Delp and Jones, 1996; Jolly et al., 1993, 1995; Logan et al., 1996;
Powers, 1988; Spandorfer et al., 1995; Williams et al., 1996). Hosey and
colleagues (1990) used the Wide Range Achievement Test to measure the
reading ability of a group of American Indian diabetic patients and found
that although many patients scored at a reading grade level of 5, the diabe-
tes education materials scored at a mean reading grade level of 10. Guidry,
Fagan, and Walker (1998) note that less than half of the cancer education
materials specifically targeting African Americans reflected the culture of
African Americans and that few were written at a reading grade level for
those with low literacy skills.
Finding 4-2 More than 300 studies indicate that health-related mate-
rials far exceed the average reading ability of U.S. adults.
Popular Sources of Health Information

News Media. The news media is a large part of America’s health informa-
tion revolution. More than a dozen exclusively health-related magazines
are easily available at grocery stores and major bookstore chains every
month in America. Magazines aimed at women, men, children, parents,
and mothers are also widely available and carry numerous articles on a
wide variety of health issues. Several of America’s largest newspapers, reach-
ing millions of people each day, carry health sections dedicated to health
news. These health sections are read by people at all literacy levels. Three
quarters of newspaper readers with NALS Level 1 literacy skills reported
reading the home, fashion, health, or reviews sections, while 85 percent of
newspaper readers with NALS Level 5 skills read these sections (health data
alone was not available) (Kirsch et al., 1993). The major broadcast and
cable networks have health journalists and health reporting. There are
multiple cable channels dedicated to health topics and other channels dedi-
cated to women’s issues such as Oxygen, that cover health as a major focus.
Some of broadcast TV’s most popular shows—Oprah and more recently a
spin-off called Dr. Phil, regularly carry health information and advice.
Health news, such as SARS, heart disease, obesity, antibiotic resistance, and
smallpox vaccination has been a centerpiece in newspaper headlines dozens
of times in 2002–2003 alone.
Advertising and Marketing. Advertising is also a prominent source of health
information. Scott-Levin, a drug market research firm in Newtown, Penn-
sylvania, reports that while all visits to physician’s offices rose 2 percent in

124 HEALTH LITERACY
the first nine months of 1998, visits for specific causes related to advertised
products and services increased much more dramatically during this time.
For example, visits for smoking cessation rose 263 percent, visits for impo-
tence increased 113 percent, visits for hair loss rose 30 percent, and visits
for high cholesterol rose by 19 percent (Maguire, 1999).
Commercial and social marketing of health information, products, and
services is now a multi-billion-dollar industry. According to the Institute for
Policy Innovation, direct-to-consumer advertising of prescription drugs
alone increased to $1.8 billion in 1999 (Matthews, 2001). These expendi-
tures are not unique. They represent a small portion of the dollars aimed at
providing health information to consumers and motivating specific health
behaviors. The United States invested some $1,080,000,000 in its recent 6-
year National Youth Anti-Drug Media Campaign (Eddy, 2003). The im-
portance of these expenditures goes beyond the dollar amount. These ex-
penditures are guided by an understanding of consumers and their desires.
These are not “information” campaigns, but rather targeted marketing
efforts designed to influence what people do by offering new products, new
services, lower barriers, and new motivations for changing their behavior—
to stop smoking, to avoid fast food, to get a mammogram or to delay
getting a mammogram. These expenditures are guided by years of market
research studies and experience that have shown what kind of language
works, what pictures appeal, and what messages compel people to act
(Wilke, 1994). Despite this investment of talent and resources, some pro-
grams fail. The most recent evaluation of the Office of National Drug
Control Policy’s National Youth Anti-Drug Media Campaign program
states: “There is little evidence of direct favorable Campaign effects on
youth. There is no statistically significant decline in marijuana use to date,
and some evidence for an increase in use from 2000 to 2001” (Hornick et
al., 2002).
One characteristic of the commercial and social marketing sector is that
the information is not provided objectively. The authors of these messages,
whether antismoking advocates or the cigarette industry, carefully select
facts, stories, and images that fall far short of full information for an
intelligent decision (Mazur, 2003: 6–11). This assault on the public may
have trained segments of the American public to be skeptical; to expect
short sound bites of information and to avoid equivocation in information.
As Mazur concludes:
Although we may talk about shared decision making in medical care and
the provider–patient relationship, the original goal of the decision scien-
tist, to provide a full discussion of risks and benefits among a full set of
alternatives, may or may not be attainable. And it is far from clear wheth-
er patients actually want to participate in such a fully shared decision-
making environment (Mazur, 2003: 177).

Family and Friends. The lay network, informal communications among

family members and friends, is another source of information about health
for many individuals. Health information is often shared through personal
experiences recounted by others. Personal stories also come from ethnic
media programming and print media coverage. These personal stories may
have the power to influence health behavior. This may be particularly true
for individuals with limited literacy skills. Friedell and colleagues (1997)
found that many individuals with limited literacy more often obtained
information about cancer from family and others who have had experi-
ences with a late-stage diagnosis rather than from reading about the
disease.
The Internet. The Internet is estimated to reach 70 million Americans with

health information. As America’s attention moves from the treatment of
disease to wellness, the number of health sites has mushroomed. Informa-
tion about Internet use among adolescents and young adults indicates that
most have used the Internet to access health information. A recent survey of
15- to 24-year-olds found that 90 percent of this population has been
online (Rideout, 2001). Of this 90 percent, 75 percent used the Internet at
least once to find health information. Searches of the Internet for health
information exceed searches for sport scores or online purchases and par-
ticipation in chat rooms (Rideout, 2001).
Questions have been raised regarding whether the Internet is a reliable
and understandable information source that appeals to and is accessible by
diverse users (e.g., Goldstein and Flory, 1997; IOM, 2002; Sikorski and
Peters, 1997). Socioeconomic status and level of education are strongly
associated with the likelihood that a consumer will obtain health informa-
tion from the Internet. Limited literacy in English and disparities in com-
puter access decrease the likelihood that the information will be available to
and understood by all health consumers (Houston and Allison, 2002). In
addition, the majority of health-related sites on the Internet are English-
language-only sites (Kalichman et al., 2001) which also serves to limit
access. The Children’s Partership conducted an analysis of online content
for low-income and underserved Americans and estimate that 44 million
adults face literacy barriers in their use of the Internet (Lazarus and Mora,
2000). Of the 1,000 web sites assessed, only 10 were accessible for adults
with limited literacy skills. Furthermore, only 20 had content in languages
other than in English that provided “practical information for a more
productive life in the United States.”
Because there is little regulation or oversight of the information posted
on the Internet, many consumers and health-care professionals are con-
cerned about the reliability of posted information (Houston and Allison,
2002; Murray et al., 2003). In fact, Healthy People 2010 includes as an

126 HEALTH LITERACY
objective increasing the proportion of web sites with health-related infor-

mation that allow the user to evaluate the quality of that information
(HHS, 2000). A meta-analysis of empirical studies of consumer health
information on the Internet by Eysenbach et al. (2002) found that 70
percent of the studies analyzed concluded that quality was a problem.
The Internet also can influence the ways health professionals and pa-
tients interact. Consumers who use the Internet to look up health-related
information may take action based on that information, including bringing
the information to their health-care provider. In a telephone survey of 521
people who had used the Internet to search for health information, those in
poor or failing health were more likely than those in good or excellent
health to talk to their physician about health information they had found
online (Houston and Allison, 2002). Murray et al. (2003) reported findings
from a telephone survey of a nationally representative sample of 3,209
people. They found that 50 percent of people who had found information
relevant to their own health took that information to their physician. Among
those who took information to the physician, 83 percent said they felt more
in control as a result, 78 percent said they felt more confident as a result,
and 6 percent reported negative feelings such as embarrassment as a result.
Murray and colleagues further reported that those taking information from
the Internet to their physician may experience a change in patient/physician
relationship depending primarily on the communication skills of the physi-
cian. For example, if the patient perceived that the physician “acted chal-
lenged” by the information the relationship was more likely to be damaged.
Finding 4-3 Competing sources of health information (including the

national media, the Internet, product marketing, health education, and
consumer protection) intensify the need for improved health literacy.
Finding 4-4 Health literacy efforts have not yet fully benefited from
research findings in social and commercial marketing.
OPPORTUNITIES TO IMPROVE HEALTH LITERACY
Evidence-Based Approaches5
Within the health sciences there is emerging literature on the effective-
ness of community-based interventions with culturally diverse groups and
increasing cultural competency by health providers (IOM, 2002). The out-
5The committee would like to thank the Agency for Healthcare Research and Quality for
their assistance with this segment of the report.

comes of a number of community-based approaches have been published,

and a sample of these are shown in Table 4-1. These approaches, while
small in number, are an important contribution to current and future ap-
proaches to health literacy, particularly to the degree that they provide
evidence of their effectiveness. As noted earlier in this chapter, this collec-
tion of approaches is not intended to be an exhaustive review of the work in
the field. Studies described in this table represent a sample of the English-
language peer-reviewed health literature that investigate the effect of an
intervention in a community-based setting. Many studies in this table re-
flect the contribution of the Agency for Healthcare Research and Quality
(AHRQ) research program, which is discussed in more detail in Chapter 6.
Additional studies were identified by searching the Medline, PsycInfo,
ERIC,6 Sociological Abstracts, and CINAHL7 databases, and through testi-
mony to the committee by experts in the field.
Four studies evaluated patient knowledge (Bill-Harvey et al., 1989;
Busselman and Holcomb, 1994; Fitzgibbon et al., 1996; Raymond et al.,
2002), and of these, only one (Bill-Harvey et al., 1989) showed positive
changes in both understanding and health behavior. Three other programs
(Fouad et al., 1997; Hartman et al., 1997; Lillington et al., 1995) showed
an improved health outcome as a result of the program, but failed to
provide evidence of increased understanding. Other evidence-based studies
are continually being identified and evaluated by the CDC’s Task Force on
Guidelines for Community Preventative Services.
Promising Approaches
In addition to these published studies, many unpublished activities are
being carried out in the community to improve health literacy. Anecdotal
evidence suggests that the limited budgets of these programs, combined
with their emphasis on intervention, result in funding being used for the
approach itself to the exclusion of formal evaluation of the program out-
come. Examples of these approaches are presented below.
Community Opportunities
Community organizations provide an opportunity to address issues of
health literacy directly. An example of this is a set of programs to address
the needs of the Navajo community. Older Navajos are particularly vulner-
able to complications of medical conditions exacerbated by a mismatch in
6Education Resources Information Center.


128 HEALTH LITERACY
TABLE 4-1 Examples of Published Studies of Community-Based

Interventions
Citation Setting Study Design Population
Bill-Harvey Senior centers and Uncontrolled n = 76 (100 enrolled,

et al., 1989 community centers trial 76 completed program)
for the elderly,
Hartford, CT
Busselman WIC voucher Randomized n = 32

and Holcomb, distribution sites in trial Controls = 31
1994 7 urban and rural Participants were receiving WIC
communities, vouchers
Kansas Controls met all WIC criteria
except for income
Controls had significantly higher
reading levels as measured by
the WRAT-R than the WIC
group (p < 0.001)
Elkind Three county region Pre-test, n = 301

et al., 2002 of Eastern post-test 185 farmworkers
Washington 115 community members
Hispanic farmworkers and their
families living in eastern
Washington
Fitzgibbon Literacy training Randomized n = 38 families (mother and at

et al., 1996 program in a controlled least one child between 7–12
Hispanic trial years).
neighborhood, Low-income Hispanics
Chicago, IL

Intervention Outcome
10-Hour osteoarthritis education program Pre-/post-test outcomes showed

designed for older low-income adults significant increase in knowledge on
with osteoarthritis. Course taught by both verbal and picture story tests
indigenous community leaders. (p < 0.001 for both), significant
increase in scores on exercise scale
(p < 0.001), improvement in attitude
toward one’s illness, and increase in
use of adaptive equipment. No
significant improvement in functioning.
Simplified dietary guidelines. Differences in comprehension of the

Control group received the unmodified seventh and tenth grade materials were
tenth grade reading level version of the not significant.
introduction to dietary guildines, while
the WIC group received a simplified
seventh grade reading level version.
Four one-act Spanish language plays Participants showed significantly greater

intended to provide education about knowledge about information from the
health and safety issues for plays (p < 0.01).
farmworkers. Participants reported enjoying the plays,
remembering the story lines, and were
willing to see additional plays if
available.
Intervention families participated in a No significant differences between

12-week-long culture-specific dietary intervention and control groups, before
intervention intended to reduce cancer and after intervention in mothers’ fat
risk through the adoption of a low-fat, intake, saturated fat intake, fiber
high-fiber diet. intake, exercise level, or nutrition
Control families received standard knowledge; or in children’s dietary
pamphlet on nutrition and health intake or nutrition knowledge.
behaviors and no classes.
Continued

130 HEALTH LITERACY
TABLE 4-1 Continued

Fouad City of Birmingham, Volunteer n = 81 completed program (130

et al., 1997 AL participants enrolled, program offered to
matched 600)
with non- 81 controls
participant City employees with high blood
controls pressure (BP)
Hartman Expanded Food and Randomized n = 134 participants

et al., 1997 Nutrition controlled 70 controls
Education Program trial,
(EFNEP), Twin randomized
Cities Metropolitan by
Area, MN instructor
(not
participant)
Kumanyika Community based Randomized n = 330

et al., 1999 Recruitment from trial Adults with a history of
supermarkets in hypertension or an abnormal
Washington, D.C. total cholesterol level, aged
in primarily 40–70.
African-American
neighborhoods
Lillington 4 WIC sites in south Randomized n = 768, 555 at follow-up

et al., 1995 and central Los controlled Pregnant WIC participants who
Angeles trial were current smokers or recent
ex-smokers

Educational program designed to reduce Participants showed significant decrease

risk factors for cardiovascular disease in mean BP (p = 0.03)
among low-literacy, unskilled workers. No significant change in BP of controls.
Participants attended health education
sessions over the course of 1 year on
different topics; weight and BP assessed
at each session, goals set, culturally
appropriate examples used, monetary
incentives offered.
Participants and controls received
materials such as newletters and
tipsheets.
Nutrition education program. Mixed model regression analyses showed

Participants received low-fat nutrition significant effects for the intervention
education curriculum. program related to changes in eating
Controls received regular EFNEP pattern scales and scales related to
materials that focus on food budgeting, attitudes of low-fat eating.
safety, and healthy eating.
Nutrition counseling. Decreases in total cholesterol and systolic

Self-help (control) group received food blood pressure observed at 12 months,
cards and nutrition guide. but there was no significant difference
Full instruction (intervention) group between the control and intervention
received these materials, video and groups.
audiotape series, and a series of 4 Outcomes did not differ by literacy
monthly classes. scores.
Culturally appropriate low-literacy Twice as many smokers in intervention

smoking cessation intervention materials group reported quitting smoking at 9
for low-income African-American and months gestation compared to control
Hispanic women. group (p < 0.01). Differences remained
Intervention group received 15-minute, at 6 weeks postpartum. Although no
one-on-one interviews, self-help guide, significant differences were observed
reinforcement cards, and participated in for relapse during pregnancy among
incentive contest. ex-smokers at 6 weeks postpartum, a
Controls received usual care; included significantly higher proportion of
written material on quitting smoking in intervention ex-smokers were still
pregnancy abstinent (79%), compared to control
ex-smokers (62%) (p < 0.01).
Continued

132 HEALTH LITERACY
TABLE 4-1 Continued

Raymond Malls and family Before-after n = 656

et al., 2002 planning clinics in comparison Females, aged 12–50, without a
eight U.S. cities: health-care or marketing
Denver, Los background, and able to read
Angeles, Chicago, English well enough to read an
San Antonio, over-the-counter label
Philadelphia,
Phoenix, Miami,
Washington, D.C.
the health literacy skills of health consumers and care providers. The Gath-
ering Place8 provides health and literacy programs for Navajo adults and
children in their homes and community centers. Bilingual, trained commu-
nity members provide services that include information on health, safety,
mental, and physical wellness, and preventive measures. A “Shima Yazhi”
lay health program offers information and support for new baby care,
parenting, and health concerns, in locations convenient to the client.
The Gathering Place also represents a collaborative program, as it
offers workshops to child care providers throughout Eastern Agency of
the reservation using videos, bilingual oral presentations, and hands-on
formats.
We need to provide opportunities for health professionals to experience the

native culture by providing workshops, presentations, or hands-on experi-
ence in selected ceremonies. We also need to provide exposure to commu-
nity members with more formal workshops in health literacy related issues.
Some topics may be “what steps need to be taken when visiting with doc-
tors,” and “talking about prescriptions and how they are supposed to work.”
Alvin Bille
The Gathering Place
8The Gathering Place is located in Thoreau, New Mexico. For more information, see http:
//www.navajo-coop.com.

Prototype product packaging and insert 85% of participants showed

for emergency contraceptive pill. understanding of at least 7 of 11
Participants were shown the package and communication objectives.
then answered questions about the Participants with lower literacy
product. significantly less likely than those with
Results reported by literacy level as higher literacy to understand almost all
measured by the REALM. of the communication objectives, but 8
of the 11 objectives were understood
by more than 80% of those with lower
literacy.
Asian Health Services9 takes advantage of community opportunities to

provide health education through one-on-one and community outreach at
nail salons, bars, sewing factories, massage parlors, beauty schools, and
community events (Asian Health Services, 2003). The program provides
group education to women thorough Northern California community cen-
ters, area businesses, and clinics. These programs offer information on
women’s health needs such as breast cancer and pap smears, as well as
information about health insurance for women and their children. The
“Health is Strength” Project run by Asian Health Services provides Korean
adults and children with health education materials (brochure, resource list,
workshops) in the Korean language. Distributed in churches and other
community venues, these materials are designed to improve knowledge and
remove barriers to health literacy. Additionally, bilingual (English and Ko-
rean) health counselors work within community social structures, primarily
churches attended by Koreans, to organize activities, serve as liasons be-
tween the Korean and medical communities, provide social support, follow
up, and improve health knowledge.
Community centers, homes, and businesses provide the opportunity for
the Centro Latino de Salud, Educación y Cultura to serve Missouri-area
Hispanic adults and children through a program called Attaining Cultural
Competency and Enriching Health Service Solutions. This program pro-
vides information and help in accessing needed educational and health
resources, a program for new and expectant mothers, interpreter and trans-
lation services, and health referrals (Centro Latino, 2003).
9Asian Health Services is based in Oakland, California. For more information, see http://
www.ahschc.org.

134 HEALTH LITERACY
Nongovernmental Organizations
Nongovernmental organizations provide an opportunity for informed
and effective advocates to have a role in shaping health literacy programs,
policies, and interventions. For example, The Institute for Healthcare Ad-
vancement has developed a set of books to assist consumers in deciding
what health issues can be dealt with at home (and how to best deal with
them) and what health issues should initiate a call to a health-care provider.
Most of these books, part of a series entitled What to Do for Health, are
available in English or Spanish; two are also available in Vietnamese. An
evaluation of one of the books carried out by Molina Healthcare found that
individuals and families who received the books visited the emergency de-
partment 6.7 percent less after receiving the books (Institute for Healthcare
Advancement, 2003).
Another example is provided by the Managed Care Consumer Assis-
tance Program (MCCAP). The MCCAP works to educate consumers about
the concepts of managed care and rights as consumers, and provide assis-
tance with dispute resolution procedures. MCCAP holds consumer educa-
tion workshops in the appropriate languages and provides one-on-one coun-
seling to consumers needing information or assistance with managed care.
Services are provided to low-income, multilingual, and multicultural com-
munities, through a network of 25 community-based organizations. These
community-based organizations include neighborhood centers, ethnic orga-
nizations, and social service agencies (MCCAP, 2003).
Collaborative Programs
Collaborations between government and community programs offer an
opportunity to develop interventions appropriate to the needs of the audi-
ence. An example of a collaborative approach is a set of materials on sex
education developed though a collaboration between the Program for Ap-
propriate Technology in Health, Austin/Travis County Health Department,
the Washington, DC, Center for Youth Services, Delaware (Maryland)
Delmarva Rural Ministries, the Tlingit and Haida Indian Tribes Central
Council, and the Children’s Theatre of Juneau. Entitled “Plain Talk,” these
materials were developed to educate and inform English-speaking and non-
English-speaking low-literate youth in response to a nationwide needs as-
sessment survey of 2,500 U.S. organizations that showed that teens espe-
cially need materials on AIDS, other STDs, and condom use (Program for
Appropriate Technology in Health, 2003).
Programs between for-profit or nonprofit agencies and community or-
ganizations provide an opportunity to develop appropriate interventions,
and to reach the intended audience. This type of collaboration can effec-

BOX 4-3
Excerpt from the Introduction to “Language Access: Helping
Non-English Speakers Navigate Health and Human Services”
Public and private organizations have begun to address language barriers to en-
sure effective communication between service providers and patients, particularly
in health care. The language gap can lead to delays in or denial of service, unnec-
essary tests, more costly or invasive treatment of disease, mistakes in prescribing
and using medication, and deterrence in patient compliance with treatment. Lan-
guage barriers are a contributing factor in health care disparities among racial and
ethnic minorities and in a lack of health insurance among immigrants and minori-
ties. In a series of federal guidances since 2000, federal agencies have reminded
recipients of federal funds of their obligation under civil rights law to provide mean-
ingful access to their services for limited-English proficient individuals. The Office
for Civil Rights in the U.S. Department of Health and Human Services (HHS) states
that language assistance should result in accurate and effective communication
between provider and client, at no cost to the client. Within the health and human
services field, affected organizations include state and local health and welfare
agencies, hospitals and clinics, managed care organizations, nursing homes, men-
tal health centers, senior citizen centers, Head Start programs and contractors. In
three federal programs, federal agencies have approved reimbursement for lan-
guage services to applicants and recipients who are limited English proficient.
HHS, in a November 1999 brief, approved the use of federal Temporary Assis-
tance for Needy Families (TANF) and state Maintenance-of-Effort (MOE) funds to
provide language services. In a 2000 letter to state Medicaid directors, the Centers
for Medicaid & Medicare Services confirmed that federal matching funds for the
State Children’s Health Insurance Program (SCHIP) and Medicaid are available
for state expenditures on interpretation and translation. At least nine states—Ha-
waii, Idaho, Maine, Massachusetts, Minnesota, Montana, New Hampshire, Utah
and Washington—have obtained federal matching funds for these services. Re-
cently, other states have enacted legislation requiring interpreters in emergency
departments and hospitals (Massachusetts and Rhode Island, respectively); a
health-care interpreters council (Oregon); and an office to address racial and eth-
nic disparities in health care, including language and cultural competency (New
Jersey).
SOURCE: Morse (2003).
tively create coalitions of existing providers by partnering a for-profit or

nonprofit organization with specific ethnic and geographically focused com-
munity providers. As an example, the Alzheimer’s Association of Los Ange-
les has developed a model to build the dementia care capability of existing
community providers such as hospitals, public health clinics, adult day care
centers, and community-based social service agencies. Using focus groups
and community input, the Alzheimer’s Association identified churches as a
visible and trusted source of health information for the Los Angeles area

136 HEALTH LITERACY
African-American community. The organization then developed a set of

education and outreach projects which involved collaboration with clergy,
social service health-care providers, and constituent representatives (Alz-
heimer’s Association of Los Angeles, 2001).
Approaches to Increasing Language Access

In 2003, the National Conference of State Legislatures’ Children’s
Policy Initiative issued a report titled “Language Access: Helping Non-
English Speakers Navigate Health and Human Services” (Morse, 2003).
This report highlights the importance of language to quality of care and
access to care, and reviews the array of promising approaches to improving
language access that are currently being carried out on the federal and state
levels. An excerpt from this report is presented in Box 4-3.
These studies and programs, both published and unpublished, offer a
variety of possible approaches and indicate both the need for effective
programs and for outcomes measures of program effectiveness. While little
evidence supports the use of any given approach, research into the value of
existing and innovative approaches on health behaviors and the effect of
participatory action and empowerment strategies can provide further direc-
tion for future approaches to address health literacy.

Finding 4-1 Culture gives meaning to health communication. Health literacy

must be understood and addressed in the context of culture and language.
Finding 4-2 More than 300 studies indicate that health-related materials far ex-
ceed the average reading ability of U.S. adults.
Finding 4-3 Competing sources of health information (including the national

media, the Internet, product marketing, health education, and consumer protec-
tion) intensify the need for improved health literacy.
Finding 4-4 Health literacy efforts have not yet fully benefited from research
findings in social and commercial marketing.
Recommendation 4-1 Federal agencies responsible for addressing disparities

should support the development of conceptual frameworks on the intersection of
culture and health literacy to direct in-depth theoretical explorations and formulate
the conceptual underpinnings that can guide interventions.
4-1.a NIH should convene a consensus conference, including stakeholders,
to develop methodology for the incorporation of health literacy improvement
into approaches to health disparities.
4-1.b The Office of Minority Health and AHRQ should develop measures of
the relationships between culture, language, cultural competency, and health
literacy to be used in studies of the relationship between health literacy and
health outcomes.
Recommendation 4-2 AHRQ, the CDC, Indian Health Service, Health Resourc-
es and Services Administration, and Substance Abuse and Mental Health Servic-
es Administration should develop and test approaches to improve health commu-
nication that foster healing relationships across culturally diverse populations. This
includes investigations that explore the effect of existing and innovative communi-
cation approaches on health behaviors, and studies that examine the impact of
participatory action and empowerment research strategies for effective penetra-
tion of health information at the community level.
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Educational Systems
“People are hearing about overweight and obesity. So they’re trying to

figure out how much food they should eat. How much is too much? They’re
asking about calories, carbohydrates, vitamins, and fiber. They’re asking
about salt, sugar, and portion sizes.
. . . As young medical students, you and I learned more about the patho-
physiology of disease than we learned about answering these questions for
our future patients.”
Vice Admiral Richard H. Carmona, M.D., M.P.H., F.A.C.S.

United States Surgeon General
American Medical Association House of Delegates Meeting
June 14, 2003
O
verall, the U.S. educational systems offer a primary point of inter
vention to improve the quality of literacy and health literacy. The
educational systems discussed in this chapter are the K-12 system,
the adult education system, and education for health professionals. Public
educational systems in the United States are influenced by national policy
and funding, but remain under the jurisdiction of and are funded by states
and localities.
142

EDUCATIONAL SYSTEMS 143
THE K-12 AND UNIVERSITY EDUCATION SYSTEMS

Elementary, middle school, high school, and university education pro-
vide an opportunity to promote health literacy, to reduce health-risk behav-
iors, and to prepare children to navigate the health-care system. Effective
health education programs should begin in early childhood and continually
build on previous knowledge (NRC, 1999). Achieving health literacy in
students is hindered by a lack of continuity in health education programs
across the many age groups.
K-12 Education
Health Education Programs

The School Health Policies and Programs Study 2000, conducted by
the Centers for Disease Control and Prevention (CDC), indicated that most
elementary, middle, and high schools require health education classes as a
part of the curriculum (Kann et al., 2001). The majority of these states (75
percent) use the National Health Education Standards (NHES) as a frame-
work to develop these programs (Kann et al., 2001). Box 5-1 displays the
NHES and some background about these standards. Some states have made
significant progress in establishing guidelines in accordance with the NHES.
A lack of consistent, cross-grade health curriculums may reduce stu-
dent health literacy. Although most elementary, middle, and high schools
require students to take health education, classes in different grades tend
not to build upon previous grades. The absence of a coordinated health
education program across grade levels may impede student learning. Kann
et al. (2001) report an increase in the percentage of elementary schools
that require health education from 33 percent in kindergarten to 44 per-
cent in grade 5. However, only 27 percent of schools require health educa-
tion in grade 6, 20 percent in grade 8, 10 percent in grade 9, and 2 percent
in grade 12.
Teacher education may affect teacher effectiveness in implementing
health and health literacy curriculums. National and international strate-
gies developed to help schools implement effective policies and programs
(e.g., Kolbe et al., 1997, 2001) are complicated by the fact that few health
education teachers majored in health education (Collins et al., 1995; Haus-
man and Ruzek, 1995; Kann et al., 2001; Patterson et al., 1996; Ubbes et
al., 1999). Only 10 percent of health education classes or courses have a
teacher who majored in health education, or in health and physical educa-
tion combined (Kann et al., 2001). Peterson and colleagues (2001) suggest
that inadequate attention to teacher health literacy has impeded student
health literacy. Many teachers feel that they are not prepared to teach
specific health topics (Peterson et al., 2001). For example, a sample of 156

144 HEALTH LITERACY
BOX 5-1
The National Health Education Standards
In 1995, the Joint Committee on National Health Standards published the National
Health Education Standards (NHES) subtitled Achieving Health Literacy (Joint
Committee on National Health Education Standards, 1995). The standards de-
scribe the knowledge and skills essential for health literacy and detail what stu-
dents should know and be able to do in health education by the end of grades 4, 8,
and 11. The standards describe a health-literate person as a critical thinker and
problem solver, a responsible, productive citizen, a self-directed learner, and an
effective communicator.
The National Health Education Standards:
1. Students will comprehend concepts related to health promotion and disease

prevention.
2. Students will demonstrate the ability to access valid health information and
health-promoting products and services.
3. Students will demonstrate the ability to practice health-enhancing behaviors
and reduce health risks.
4. Students will analyze the influence of culture, media, technology, and other
factors on health.
5. Students will demonstrate the ability to use interpersonal communication skills
to enhance health.
6. Students will demonstrate the ability to use goal-setting and decision-making
skills to enhance health.
7. Students will demonstrate the ability to advocate for personal, family, and com-
munity health.
The NHES identified obstacles that continue to impede health education programs,
including:
• Lack of appreciation for the relationship between health status and success in
academic and work performance,
• Low levels of commitment by school board members and administrators,
• Inadequately prepared teachers,
• Insufficient funding for resources and staff development,
• Overcrowded curricula with little or no time for health education (Pateman,
2002; Thackeray et al., 2002),
• Unconnected and seemingly irrelevant health instruction,
• Lack of recognition of the contribution made by health education to the achieve-
ment of the academic goals of schools,
• Failure to adequately document student performance in achievement of health
literacy.

elementary school staff from five schools in Philadelphia felt only “some-
what prepared” to teach health education (Hausman and Ruzek, 1995).
These findings highlight the importance of professional development for
teachers who provide classroom health education to young students.
Many teachers are also required by state guidelines to include specific
topics and standards within their curriculums, often in response to state-
mandated tests. Even within good health education curricula, teachers can-
not address all topics and issues at a single grade level. Although health
education may be included within the required curriculum, it might not be
included within state-mandated tests and therefore these topics will receive
less attention in the classroom (Pateman et al., 1999). A call to strengthen
school health education by health education with state assessment require-
ments was made soon after the NHES were published (Collins et al., 1995),
but a low level of grant support for health literacy assessment persists.
A national health promotion and disease prevention report recom-
mends that the United States increase the proportion of middle, junior, and
senior high schools that provide health education to prevent health prob-
lems in areas such as unintentional injuries; violence; suicide; tobacco use
and addiction; alcohol and other drug use; unintended pregnancy; HIV/
AIDS and STD infection; unhealthy dietary patterns; inadequate physical
activity; and environmental health (HHS, 2000).
The World Health Organization (1996) has described several barriers
that may impede the implementation of school health programs at local,
state, national, and international levels. First, education, health, and politi-
cal leaders, as well as the public at large, often do not possess accurate
knowledge of modern school health programs and their potential impact
on health. Second, many believe the most important function of schools to
be the improvement of language, mathematical, and scientific skills. Third,
some may not support modern school health programs because some ele-
ments of some programs may be controversial (e.g., school programs to
educate about, and prevent, HIV infection, other prevalent STDs, and
unintended pregnancy). Fourth, modern school health programs require
effective collaboration, especially among separate education and health
agencies.
Unfortunately, among 38 states that participated in the School Health
Education Profiles Study, the percentage of schools that required a health
education course decreased between 1996 and 2000, as did the percentage
of schools that taught about dietary behaviors and nutrition, and about
how HIV is transmitted. During the year 2000, only 27 percent of schools
required health education in grade 6, a number that fell to 2 percent in
grade 12 (Storch et al., 2003). A similar pattern is observed in Canadian
schools. In 1999, over 70 percent of Canadian school districts reported that
health education was mandatory in grades 3 through 5, but only 20 percent

146 HEALTH LITERACY
reported that it was mandatory in grade 12 (McCall et al., 1999). When

children are at an age when health risk behaviors increase (Smith, 1999),
American schools require little education about health (Grunbaum et al.,
2002). Unless health education is considered part of basic education, the
quantity and quality of health education in U.S. elementary and secondary
schools are likely to deteriorate further.
A report from an Institute of Medicine Committee on Comprehensive
School Health Programs in Grades K-12 (IOM, 1997) recommended that
the United States improve its school health programs. A report from the
World Health Organization (1997) made similar recommendations for all
nations to take similar measures. Recent surveys show that school adminis-
trators, parents, students, and the public at large all want elementary and
secondary schools to implement more comprehensive school health pro-
grams (The Gallup Organization, 1994; Marzano et al., 1998).
Health professionals, such as school nurses, food service directors,
health teachers, physical education teachers, and school psychologists, are
already working in many elementary and secondary schools (Marx et al.,
1998). Many state education and health departments also employ staff to
help schools implement school health programs, as do many national non-
governmental education and health organizations (CCSSO, 2003). These
programs provide a potential target for further intervention.
Science Education
Science education provides a clear opportunity for implementation of
health literacy education programs and content. An example of this asso-
ciation is the Curriculum Linking Science Education and Health Literacy
program. This project transformed inner-city children’s, teachers’, and par-
ents’ or care givers’ experiences with food into an inquiry-based science
program. Guidelines for science education include content standards for
personal and community health (American Association for the Advance-
ment of Science, 1993; NRC, 1996).
Science teachers have indicated that scientist participation can
strengthen science education. A survey called “The Bayer Facts of Science
Education V,” conducted by Bayer Corporation and the National Science
Teachers Association (1999), indicated that 98 percent of the science
teachers believe that direct student–scientist interaction within classroom
was important. These findings suggest an opportunity for science and
health-care professionals to participate in school science and health educa-
tion programs to improve the health literacy of pre-college students. In
fact, more than half of 107 elementary school teachers at 31 schools re-
ported wanting classroom visits by health professionals (Thackeray et al.,
2002).

Literacy Education
The subject of literacy instruction and achievement in schools, particu-
larly reading, is more conspicuous in the political and mainstream arenas
than is health education. While health education holds promise in promot-
ing full health literacy insofar as it leads to the acquisition of the necessary
health-related knowledge, the issue of basic literacy is equally essential to
full health literacy. As detailed in previous chapters, much of the research
on health literacy documents the difficulties with printed health texts expe-
rienced by adults who are low in overall literacy skill.
Two influential reports have been issued by the National Research
Council (NRC, 1998) and the National Institute of Child Health and Hu-
man Development (National Reading Panel, 2000) addressing the failure of
schools to produce adults who are sufficiently literate to participate in an
increasingly information-driven and competitive economy. These reports,
along with a collection of Congressional mandates, helped lead to the No
Child Left Behind legislation,1 which is driving major instructional change
designed to improve the levels of achievement in the schools. The major
strategy of No Child Left Behind is to hold all schools accountable for
ensuring that students achieve certain standards in subjects that comprise
basic education, including language, science, and mathematics. It is too
soon to report any results of these changes, but increasing numbers of
schools and school districts are attending to the issues raised by the national
concern with literacy achievement.
College and University Health Education

Nearly two-thirds of the 27 million 18- to 24-year-olds in the United
States become college undergraduates (U.S. Department of Education,
2001). Unfortunately, relatively few of the nation’s 2- and 4-year colleges
and universities currently require or provide education about health (Keel-
ing, 2001; Patrick et al., 1992). In a summary from a symposium on health
and higher education, the Association of American Colleges and Universi-
ties suggested that these institutions are well situated to address issues
critical to health literacy, “. . . to discover the causes and cures for diseases
and to explain how people can be engaged, individually and collectively, in
the improvement of their own lives and the lives of others” (Burns, 1999).
But a summary from their 2001 symposium noted that: “. . . as a nation,
we have not made the health of college students a priority; we lack a strong
commitment to addressing health on campus, a coordinated strategy to
1No Child Left Behind Act of 2002. P.L. 107-110.

148 HEALTH LITERACY
improve health among students, and—most important—a focus on the

capacity of students themselves to contribute to solving health problems”
(Association of American Colleges and Universities, 2002).
One of the National Health Objectives calls for the United States by the
year 2010 to “increase to 25 percent the proportion of college and univer-
sity students who receive information from their institution on each of the
six priority health-risk behavior areas (injuries, tobacco use, alcohol and
illicit drug use, sexual behaviors that cause unintended pregnancies and
sexually transmitted diseases, dietary patterns that cause disease, and inad-
equate physical activity)” (HHS, 2000). In 1995, only 6 percent of 18- to
24-year-old undergraduates in the United States received information about
all six topics (Douglas et al., 1997), despite the fact that these college
students were substantially more likely to engage in most of these health
risk behaviors than high school students (Kann et al., 1996). Neither stan-
dards nor instruments to assess their attainment have been developed to
support critical health knowledge and skills that undergraduate students
could acquire as part of their college education.
Finding 5-1 Significant obstacles and barriers to successful health lit-

eracy education exist in K-12 education programs.
Strategies and Opportunities in K-12 and University Systems

Although the difficulties in addressing health literacy in education are
considerable, targeted solutions can be developed if the factors that contrib-
ute to these difficulties are identified. State and local programs can use the
educational system’s potential for addressing the issue of health literacy to
produce change. St. Leger (2001) proposes that government investment
into teacher professional development, research into school health frame-
works, and wider dissemination of effective school health programs will
improve health literacy. In addition to health education programs, opportu-
nities for health literacy instruction exist that embed health literacy content
into basic literacy teaching. In this section, these two types of approaches
are described, issues with the assessment of health literacy in educational
settings are explored, and examples of ongoing approaches are offered.
Opportunities for Health Education Programs

Many studies have provided evidence that school health programs can
improve critical health knowledge, attitudes, and skills among elementary
and secondary school students and the evidence suggests that school health
programs can improve health behaviors and health outcomes (Kolbe, 2002).
The CDC has initiated a project called “Programs-That-Work” to identify

effective health education programs that reduce health-risk behaviors (for

review, see Collins et al., 2002). These health-risk behaviors are those
stressed by the U.S. Department of Health and Human Services Healthy
People 2010 program (2000). Lohrmann and Wooley (1998) have pro-
posed that successful health education curriculums should meet the follow-
ing criteria:
1. Be research-based and theory-driven.

2. Include information that is accurate and developmentally appro-
priate.
3. Actively engage students using interactive activities.
4. Allow students to model and practice relevant social skills.
5. Discuss how social or media influences affect behavior.
6. Support health-enhancing behavior.
7. Provide adequate time for students to gain knowledge and skills.
8. Train teachers to effectively convey the material.
Health education programs have the opportunity to provide students

with practice in negotiating the health-care system. Specific instruction
might include such activities as roleplaying to become familiar with the
many different interactions that occur between the health-care provider and
the patient (Purtilo and Haddad, 1996). Arguably the most effective means
to improve health literacy is to ensure that education about health is a part
of the curriculum at all levels of education. Schools and colleges could
incorporate health literacy education into a range of exiting programs and
services such as health services, health education, food services, physical
education, and counseling, psychological, and social services (Kolbe, 1986).
Strategies for Health Literacy Instruction

With the increasing pressure on schools today to include more and
more academic content, educators are justifiably reluctant to add one more
content area to their already overflowing plates. However, health literacy
instruction can be embedded into existing science and health education,
and even mathematics and social studies, as well as literacy instruction for
children and adults.
There is a sound justification for embedding health literacy instruction
into existing literacy instruction for children and adults. Educational re-
search for at least the last few decades has documented the impact of
context and content on learning, retention, and transfer. This research has
shown that learners retain and apply information best in contexts similar to
those in which they learned it (Bereiter, 1997; Mayer and Wittrock, 1996;
Perkins, 1992).

150 HEALTH LITERACY
Literacy practitioners and scholars have taken these findings and ap-
plied them to the vexing problem of why literacy skills learned in school are
often not applied to literacy tasks in life. One obvious implication of this
research is that reading and writing skills must be learned in the context of
texts and literacy purposes that readers will encounter out in the world.
Therefore, one needs to teach reading skills in those contexts. Health texts
and purposes for reading them make up one of those real-life literacy
domains. A survey conducted by Bayer and the National Science Teachers
Association (Bayer Corporation and the National Association of Science
Teachers, 1999) indicated that 98 percent of science teachers surveyed
believe that direct interaction within classroom with health professionals
was important. These findings suggest that the participation of health-care
professionals in school health education programs would improve the health
literacy of pre-college students.
Embedding health literacy instruction can be done with the two types
of literacy instruction needed to improve health literacy: basic print literacy
instruction and literacy instruction in text types common to the field of
health literacy. This latter type of instruction introduces the idea of teach-
ing functional print literacy based on using and understanding real-life text
types. Several studies, funded by the National Science Foundation and the
Interagency Educational Research Initiative, have examined the outcomes
of introducing more expository texts2 into primary-grade instruction dur-
ing years typically devoted to basic literacy learning. One study looked at
the effect on basic literacy growth of adding non-narrative texts to the
typical mix of stories used by first- and second-grade teachers (Duke, 2000).
Results indicate that students whose teachers diversified their materials
learned as much as those who did not, confirming that this approach was
not detrimental to the development of beginning reading skill and writing
abilities.
A longitudinal study, termed the TEXT study (Purcell-Gates and Duke,
2000), has shown that children as young as second and third graders can
grow in their abilities to read and to write two types of texts often found in
the health field: science informational texts and science procedural texts.
Since individual unfamiliarity with different text types often used to convey
health information is a health literacy challenge, this study is important in
that it is the only one to date that addresses the teaching of text types
specifically, and, in this case, the teaching of health literacy-significant text
types. For this study, second- and third-grade teachers were randomly as-
signed to one of two conditions: (a) The Authentic Only condition, where
teachers had their students reading science informational and science proce-
2Expository texts are statements or rhetorical discourse intended to give information about
or an explanation of difficult material.

dural texts that were constructed similar to those found in the real world
for real-world purposes of learning new science information or for actually
conducting experimental procedures. They also wrote science informational
texts and science procedural texts for real-world purposes of providing
readers with information of providing written procedures that allow read-
ers to conduct scientific investigations. (b) The Authentic-plus-Explicit con-
ditions added explicit teaching of language features associated with each
text type to the authentic reading and writing just described for condition
(a). Examples of language features include (for science informational texts)
generic nouns (whales rather than Willy the Whale) and timeless verbs
(whales eat rather than Willy the Whale ate) and (for science procedural
texts) a materials section before the ordered steps that are usually num-
bered.
Analysis of the TEXT data indicates that the children in both condi-
tions grew significantly in their abilities to read and write these science-
related text types. Although no significant differences were found due to
explicit teaching of the language features, their reading comprehension and
writing ability of these two types of texts were significantly related to how
authentic the reading and writing assignments were in each class. All of the
students learned the features of these two text types commonly employed in
the health field, and those students whose teachers used more ‘authentic’
texts and purposes for reading and writing them learned them to a greater
degree. The fact that this can occur at such an early age implies that one
does not need to wait until middle or high school to begin teaching about
the different text types so commonly used to convey health information.
This study was funded by the National Science Foundation and the Inter-
agency Education Research Initiative.
Several studies funded by the National Science Foundation and the
Interagency Educational Research Initiative have examined the outcomes of
introducing more expository texts into primary-grade instruction during
years typically devoted to basic literacy learning. A study by Duke (2000)
looked at the effect on basic literacy growth of adding non-narrative texts
to the typical mix of stories used by first- and second-grade teachers. Re-
sults are showing that students whose teachers utilized different types of
texts in the lessons grew as much as those who did not, confirming that
children this young could read and learn from non-narrative texts and that
this approach was not detrimental to the development of beginning reading
skill and writing abilities.
Assessment of Health Literacy in Educational Settings

It is possible to evaluate basic literacy and functional print literacy, and
it is important to be clear when conceptualizing and building valid assess-

152 HEALTH LITERACY
ments. Effective recommendations depend on clear, accurate assessments.

But much work remains to be done on the specific and targeted issue of
health literacy assessment in educational settings.
Educational assessments generally include formative and summative
components. Formative assessments are constructed so that test results can
directly inform and shape ongoing instruction. They should provide feed-
back to teachers and to school systems regarding how well the instruction
meets the learning needs of their students. The major effort of assessment
should be devoted to informed formative assessment.
Summative assessments are a part of instructional contexts, and serve
primarily to rate, or grade, the student on how well they learned what was
taught. Within the health literacy context, summative assessments can be
used to make judgments about individual persons regarding their “level” of
health literacy.
Health literacy programs in schools and colleges can be designed to
accomplish four distinct, but overlapping and interdependent, types of goals
(Kolbe, 2002). First, such programs can be designed to improve health
literacy; that is, improve important health knowledge, attitudes, and skills.
The Council of Chief State School Officers (which represents the nation’s
state school superintendents) established a State Collaborative on Assess-
ment and Student Standards (SCASS) to assess student achievement in sev-
eral context areas. To assess health literacy, SCASS created an Assessment
Framework Matrix (Council of Chief State School Officers and State Col-
laborative on Assessment and Student Standards, 1998) that was used to
develop test items within nine content areas3 and six core concepts and
skills4 that reflect the NHES for elementary, middle, and high school stu-
dents (Joint Committee on National Health Education Standards, 1995).
The major purpose of the SCASS Health Education Assessment Project is to
improve health literacy by guiding improvements in school health educa-
tion planning and delivery (Pateman, 2003).
Examples of Current Approaches

Several state organizations have developed programs to address health
literacy education in kindergarten through high school. Many examples of
programs are detailed in the State Official’s Guide to Health Literacy
3These nine content areas are: alcohol and other drugs, injury prevention, nutrition, physi-
cal activity, sexual health, tobacco, mental health, personal and consumer health, and com-
munity and environmental health.
4 These six core concepts and skills are: accessing information, self-management,
internal and external influences, interpersonal communication, decision-making/goal-
setting, and advocacy.

(Matthews and Sewell, 2002). For example, the state of California has
developed a tool to aid health education curriculum development at the
local level and to promote collaborations between schools, parents, and the
community, called “Health Framework for California’s Public Schools,
Kindergarten through Grade Twelve” and the State of Alaska produced
“Healthy Reading Kits” for grades 2 through 8 (Matthews and Sewell,
2002). The state of New Jersey has implemented core curriculum content
standards for comprehensive health and physical education programs which
include health literacy. The goal of the standards is to develop citizens who
are both health-literate and physically educated. The standards for compre-
hensive health and physical education emphasize six primary areas (Morse,
2002):
• Behaviors that cause intentional and unintentional injuries

• Drug and alcohol use
• Tobacco use
• Sexual behaviors that lead to sexually transmitted diseases, includ-
ing HIV infection, and unintended pregnancy
• Inadequate physical activity
• Dietary patterns that cause disease
Federal programs to address health literacy include the “Media Smart

Youth” program developed by the National Institute of Child Health and
Human Development (NICHD), and associated with Centers for Disease
Control youth media “VERB” campaign (CDC, 2002). With support from
the Academy for Educational Development (Academy for Educational De-
velopment, 2002), NICHD has developed this youth health and fitness
media literacy campaign, which has the potential to enhance 9- to 13-year-
old after-school programs’ curriculums in health literacy. Another example
of federal activity in health literacy is the Curriculum Linking Science Edu-
cation and Health Literacy program, funded by the National Center for
Research Resources. The goal of this project was to transform the food
experiences of inner-city children, teachers and parents, and caregivers into
an inquiry-based science program. Barton and colleagues (2001) reported
that mothers who spend time engaged in science activities with their chil-
dren are more likely to have a more personal, dynamic, and inquiry-based
view of science; whether this also affects parent’s or children’s health lit-
eracy is unclear.
The private sector has also developed approaches which may improve
health literacy in youth. Inflexxion® Incorporated has developed “Special
Report” (Inflexicon, 2001), a curriculum-based tobacco education pro-
gram for middle and junior high school students, supported by the National
Cancer Institute small business innovative research program. The short

154 HEALTH LITERACY
program includes an interactive game, animation, and audio; a section on

media literacy helps students analyze tobacco advertisements; and a skill-
building module includes video of situations in which actors are presented
with tobacco and peer stories from older youths who have used or avoided
tobacco. The effectiveness of this program is being examined in a controlled
clinical trial of 270 children from 12 schools throughout the Massachusetts
region representing diverse urban, suburban, and rural populations as well
as socioeconomic, racial, and cultural backgrounds. Inflexxion® hopes to
distribute this program to schools, community organizations associated
with tobacco control, and pediatric practices.
THE ADULT EDUCATION SYSTEM5

Individuals were asked to provide information on their use of adult
education programs to improve reading, writing, math, or English language
skills in the 1992 National Adult Literacy Survey (NALS). Nearly half (46.8
percent) of those who reported using English language instruction took
either a basic skills or English language adult education course. In addition,
11.3 percent of high school dropouts and 13.3 percent of high school
graduates with NALS Levels 1 or 2 skills reported participation in basic
skills classes. This suggests that adult education is an important resource,
and may be particularly important to individuals with limited literacy or
limited English proficiency.
The Context of the Adult Education System

A major source of support for American adult education programs in
literacy is the U.S. adult basic education and literacy (ABEL) system. ABEL,
founded through the 1998 Workforce Investment Act,6 receives $500 mil-
lion in federal funds and $800 million in state funds annually. ABEL pro-
grams provide classes in topics that support health literacy including basic
literacy and math skills, English language, and high school equivalence.
ABEL is administered by state agencies, usually education, labor, or
employment departments, which in turn fund local service programs. Some
ABEL programs also receive local governments or private support. ABEL
administration, research, and information activities are carried out by the
U.S. Department of Education’s Office of Vocational and Adult Education,
5The committee thanks John Comings, Ed.D., for his contributions to this section of the
report.
6Workforce Investment Act of 1998. P.L. 105-220, 1998 H.R. 1385, enacted on August 7,
1998, 112 Stat 936. Codified as: Section 504 of the Rehabilitation Act, 29 U.S.C. § 794d.

the National Institute for Literacy, and the National Center for the Study of
Adult Learning and Literacy (NCSALL). Thus, ABEL represents a collabo-
rative activity that spans government, private, and volunteer activities at
the federal, state, and community levels, which could have a large effect on
health literacy.
In fiscal year 1998, the ABEL system provided English language ser-
vices to approximately 2 million adults, high school equivalence prepara-
tion services to 800,000 adults, and basic skills services to 1,300,000 adults
(U.S. Department of Education, 1999). Each year, between 3 million and 4
million adults spend some time in an ABEL program. Though the mean
hours of participation is only 72, a significant percentage of students drop
out within the first 30 hours, and so more than half of the students are
receiving at least 100 hours of instruction. Most of these adults are in the
primary target population of health literacy programs. ABEL programs are,
therefore, an effective venue for health literacy activities. However, the
potential demand for these services was much greater and may be affected
by the fact that the ABEL system has limited resources for one-time devel-
opmental costs that produce curriculum, materials, and teacher training
designs. These efforts, and effective adult education programs to improve
health literacy, could be made available to more people through a coopera-
tive effort between the health system and the ABEL system to undertake a
research and development agenda that would lead to educational programs
that served the needs of health literacy and the needs of English language
and basic skills instruction.
Strategies and Opportunities in the Adult Education System

Adult education theory maintains that people prefer and want informa-
tion that is relevant to their current situation, and they tend to learn better
when the environment is open and encouraging (or facilitative) rather than
narrow and passive (or restrictive) (Knowles, 1980). The complexities of
the health-care system today require that information be constructed and
delivered with consideration for literacy and culture, and cast within a
problem-solving or behavioral context (the “how-to” approach). This how-
to approach should be geared to the behavioral information needed to act.
While general facts about cancer, nutrition, or care-giving are helpful, un-
less the health information is cast within a problem-solving context, it is
often lost. In many print and oral instructions, the reader does not encoun-
ter the behavior information early enough. Most people need to have advice
that makes sense to them and is logical from their own perspective (Doak et
al., 1996). For example, instructions provided to an elderly man with dia-
betes on the importance of foot care would be more effective if the informa-
tion is presented within the context of how to achieve the necessary care.

156 HEALTH LITERACY
Green and Kreuter (1999) reported that simple acquisition of knowl-

edge does not necessarily produce change: there may be motivational and
informational gaps. In other words, “getting the message out” does not
mean that people will act on the information. There is a need for better
understanding of how people learn, as well as what factors influence infor-
mation-seeking and how literacy contributes to health behaviors. Theories
of learning and health education principles can offer explanations for health
behaviors and actions and can point to promising ways to create meaning-
ful messages (Meade, 2001). Learning theories can aid in recognizing the
mechanisms whereby knowledge, attitudes, and behaviors can be poten-
tially modified and adopted (Bandura, 1977; Becker, 1974; Becker et al.,
1977; Bigge, 1997; Hochbaum, 1958; Pender, 1996; Rosenstock, 1966).
Freire (1973) suggests that knowledge about health issues can be gained
through participatory methods. This approach, called problem-solving edu-
cation, encourages learners to be critical thinkers about health issues: the
process encourages ongoing learner participation and input. This perspec-
tive of involving consumers in the educational process is consistent with
literacy solutions that value the voice of the people.
Incorporating Health Content into Adult Education Programs

Most classes for adults studying for their high school equivalence are
narrowly focused on the requirements of the GED test or other certification
system. However, health content has always been part of basic skills and
English language services. About 10 years ago, a number of professionals in
the field became interested in expanding health content in the ABEL cur-
riculum. This interest arose out of a need to find content that was compel-
ling for adults so as to increase their motivation to practice the language,
literacy, and math skills learned in class, and health is a topic of high
interest to almost all students. Initial efforts focused on specific diseases,
such as breast cancer, and traditional school health topics, such as nutri-
tion. Work by NCSALL has expanded this focus to include the issues of
access, navigation, prevention, screening, and chronic disease management
(Rudd, 2002).
Adult literacy researchers have begun to empirically examine the effects
of using authentic (real-life) materials and activities for teaching adults to
read and write. For example, Howard-Pitney et al. (1997) tested the effect
of dietary intervention for low-literacy, low-income adults and found an
increase in nutrition knowledge. A federally funded study, using a nation-
wide sample of adult literacy classes and students, found that students
whose teachers incorporated texts for real-life purposes (like reading news-
papers to learn the news rather than underline the verbs) began to read and
write more often in their lives and to read and write more complex texts

(Purcell-Gates et al., 2000, 2002)7 In contrast to these findings, Murphy et

al. (1996) reported no significant change in nutrition knowledge or self-
reported consumption behaviors.
These findings are beginning to be incorporated into adult literacy
teaching. For example, a handbook has been published for teachers who
wish to begin to use more real-life texts and literacy activities while still
teaching their students the skills of reading and writing (Jacobson et al.,
2003). Teachers are encouraged to identify the types of life activities their
students engage in that require more advanced reading skills. The domain
of health and health maintenance is one obvious topic.
Within this type of instruction, teachers obtain typical health-related
texts like prescription labels, consent forms, health history forms, and
health-related Internet sites and construct lessons in which students learn
not only how to decode and comprehend health-specific words but also
what information is being conveyed by different texts and why it is impor-
tant. The students are taught measurement terms, commonly used abbre-
viations, how to keep track of vaccinations and medications, and so on.
Reports from existing programs for adult health literacy instruction have
been positive (Doak et al., 1996). Building on students’ present needs and
experiences may add to already existing programs to bring more relevancy
and meaning to the instruction (Perkins, 1992; Purcell-Gates et al., 2000).
Findings from national surveys indicate that both state directors of adult
education programs and adult education teachers are interested in and
supportive of an integration of literacy skill development and health-related
tasks and content (Rudd and Moeykens, 1999; Rudd et al., 1999).
Finding 5-2 Opportunities for measuring literacy skill levels required

for health knowledge and skills, and for the implementation of programs to
increase learner’s skill levels, currently exist in adult education programs
and provide promising models for expanding programs. Studies indicate a
desire on the part of adult learners and adult education programs to form
partnerships with health communities.
EDUCATION FOR HEALTH PROFESSIONALS

There are many demands for time and space in the curricula of health
professional schools, including schools of medicine, dentistry, pharmacy,
nursing, and public health. Further, continuing education efforts compete
with thousands of topics for the attention of busy health-care providers.
Regardless, improved education in health literacy is critical to the develop-
7The reading and writing of more complex texts is associated with higher levels of literacy
as defined by the NALS assessment.

158 HEALTH LITERACY
ment of competent physicians and other health-care providers who can help
to improve health literacy and to limit the negative effects of limited health
literacy among patients. Furthermore, research should investigate whether
increased health literacy skills in care providers such as medical assistants,
home health-care workers, and home health aides could contribute to im-
proved health-care quality and reduced medical errors. Approaches to edu-
cation for health professionals should include both curricular and continu-
ing education to reach the greatest number of providers at all stages of
career development. The approaches described below may provide a start-
ing point for increased integration of health literacy concepts and skills into
professional and continuing education programs. Further information on
the relationship of health literacy to health-care quality for all categories of
providers could help to develop future directions for such integration.
Curricular Approaches
Few official requirements or curricula address health literacy in schools
of medicine, public health, nursing, dentistry, or pharmacy. Health literacy
issues may be addressed under topics such as patient communication, but
they are generally not systematically included in these topics. Plomer and
colleagues (2001) reported on the development and implementation phases
of a project to improve medical students’ communication with limited lit-
eracy patients by incorporating literacy content into the medical student
curriculum. In this study, the use of standardized patient cases regarding
cancer screening was implemented and results revealed that group discus-
sion about literacy was prompted.
There are a few examples of courses or curriculums that should be
noted. In 1995, the Harvard School of Public Health initiated an ongoing
graduate course for students in public health that focused on health literacy
studies, research, theories, and implications (NCSALL, 2001). In addition,
the Harvard School of Public Health provides a web site (http://www.hsph.
harvard.edu/healthliteracy) about health literacy for researchers and practi-
tioners that includes a video slide show, curriculums, literature reviews,
annotated bibliographies, and policy initiatives. Another curricular ap-
proach took place at the University of Colorado Medical School in Denver
where a course on health literacy for medical students was developed and
taught during 2000 as part of a grant. This was a temporary initiative
however, and was not made a permanent part of the curriculum.
A more formal approach has been instituted at the University of Vir-
ginia School of Medicine (Dalton, 2003). This curriculum includes an
introductory lecture for first-year medical students, departments, residents,
and external institutions that request a presentation on health literacy. A
faculty development handbook is given to all faculty teaching courses in

the first and second year, which provides background information and a
list of available health literacy materials. Health literacy concepts are also
integrated into other courses in the medical school curriculum; for ex-
ample, patient case studies are presented in the second-year “Clinical Prob-
lems” course in which patients experience barriers related to communica-
tion misunderstandings and language issues. Also in the second year, the
required community preceptorship includes a health literacy component. A
fourth-year elective focusing on health literacy issues and including a ser-
vice component is currently in development and will likely be offered in
the spring of 2004. The University of Virginia (UVA) School of Medicine
also provides a web interface to help other institutions develop health
literacy curricula. It is made up of three main groups of information which
can be individually tailored to the needs of an institution: (1) an outline on
how UVA established its curriculum, with reference materials that include
a faculty development handbook and examples of written cases used at
various points of the curriculum; (2) an introductory health literacy lec-
ture, examples of illustrations, and a bibliography and resources list; (3)
standardized patient cases that illustrate work with patients with limited
literacy, that also show how to work with interpreters for the deaf and for
non-English-speaking patients; some of these case studies also integrate
cultural competency issues.
Continuing Education Approaches

Most health literacy training for health professionals is done under
continuing education umbrellas. Continuing medical education (CME) con-
sists of those educational activities that serve to increase knowledge, skills,
and performance of health professionals. They often are intended to update
health professionals on new techniques as well as to expose them to new
ideas and concepts relevant to their daily practice (ACCME, 2002). The
Accreditation Council for Continuing Medical Education (ACCME) re-
ports that over 45,000 directly sponsored CME courses were offered in
2002 to both physician and nonphysician participants (ACCME, 2003).
The Coalition for Allied Health Leadership (CAHL) formed a health
literacy team during their 2003 meeting to assess health literacy practices of
allied health professionals at the national level. The CAHL team developed
a survey to assess further the current level of awareness of the allied health
community and to develop materials to help the allied health community
better meet their needs. The survey was electronically sent to members of
the Health Professions Network and the National Network of Health Ca-
reer Programs in Two Year Colleges. Approximately one-third of the re-
spondents were unaware of the issues surrounding health literacy, or un-

160 HEALTH LITERACY
aware of its impact on patient care. In addition, the same percentage also
reported a lack of any institutional policy within their organization ad-
dressing health literacy or no assessment of the effectiveness of existing
policies (Brown et al., in press).
The American Medical Association (AMA) has developed several pro-
grams in professional continuing education in health literacy since adopting
a policy in 1998 that recognized that limited patient literacy affects medical
diagnosis and treatment. The AMA and the AMA Foundation have since
raised awareness and shared best practices about health literacy. In 2003,
the AMA Foundation, American Public Health Association, the National
Council on the Aging, and other public health organizations formed the
Partnership for Clear Health Communication, a coalition to increase aware-
ness of health literacy and its impact on the nation’s health, and introduced
a solution-oriented program that includes the “Ask Me 3” program that
promotes communication between health-care providers and patients
(AMA, 2003b; Ask Me 3, 2003). In conjunction with California Literacy,
Inc., and the California Medical Association (CMA), the AMA and AMA
Foundation developed the California Statewide Health Initiative that pro-
motes provider–patient communication as a basis for patient understanding
(AMA, 2003a). The AMA Foundation, with support from Pfizer, Inc., also
links organizations across the country through Health Literacy Coalition,
and provides grants to health literacy community service projects.
The AMA Foundation has developed and distributed educational kits
to physicians and health-care professionals. This program, “Health Lit-
eracy, Let Your Patients Understand,” includes a CD-ROM for use by
providers in a continuing education curriculum. The 2003 Health Literacy
Educational Kit is the Foundation’s primary tool for informing physicians,
health-care professionals, and patient advocates about health literacy. The
2003 Health Literacy Educational Kit is an expanded version of the kit
introduced in 2001. Included are a manual for clinicians, a new video
documentary, reprintable information, guidelines for continuing medical
education credit, and additional resources for education and involvement.
The AMA Foundation provides these kits free to AMA Alliance chapters
and state, county, and specialty medical societies that make a formal com-
mitment to launch health literacy educational programs of their own, and
to that end provide an extensive “train the trainer” program with a faculty
guide to the clinician workshop and guidelines for local implementation
planning.
Finding 5-3 Health professionals and staff have limited education,

training, continuing education, and practice opportunities to develop skills
for improving health literacy.

Finding 5-1 Significant obstacles and barriers to successful health-literacy edu-

cation exist in K-12 education programs.
Finding 5-2 Opportunities for measuring literacy skill levels required for health
knowledge and skills, and for the implementation of programs to increase learner’s
skill levels, currently exist in adult education programs and provide promising mod-
els for expanding programs. Studies indicate a desire on the part of adult learners
and adult education programs to form partnerships with health communities.
Finding 5-3 Health professionals and staff have limited education, training, con-
tinuing education, and practice opportunities to develop skills for improving health
literacy.
Recommendation 5-1 Accreditation requirements for all public and private edu-
cational institutions should require the implementation of the NHES.
Recommendation 5-2 Educators should take advantage of the opportunity pro-

vided by existing reading, writing, oral language skills, and mathematics curricu-
lums to incorporate health-related tasks, materials, and examples into existing les-
son plans.
Recommendation 5-3 HRSA and CDC, in collaboration with the Department of

Education, should fund demonstration projects in each state to attain the NHES
and to meet basic literacy requirements as they apply to health literacy.
Recommendation 5-4 The Department of Education in association with HHS

should convene task forces comprised of appropriate education, health, and public
policy experts to delineate specific, feasible, and effective actions relevant agen-
cies could take to improve health literacy through the nation’s K-12 schools, 2-year
and 4-year colleges and universities, and adult and vocational education.
Recommendation 5-5 The National Science Foundation, the Department of

Education, and the NICHD should fund research designed to assess the effective-
ness of different models of combining health literacy with basic literacy and instruc-
tion. The Interagency Education Research Initiative, a federal partnership of these
three agencies, should lead this effort to the fullest extent possible.
Recommendation 5-6 Professional schools and professional continuing educa-

tion programs in health and related fields, including medicine, dentistry, pharmacy,
social work, anthropology, nursing, public health, and journalism, should incorpo-
rate health literacy into their curricula and areas of competence.

162 HEALTH LITERACY
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Health Systems
Mr. G. is a 64-year-old man with chronic hypertension, diabetes, a high

cholesterol level, and gout. He saw his primary care doctor because his left
leg was swollen and painful. His doctor diagnosed an early cellulitis and
prescribes an antibiotic to be taken for 10 days.
After 4 days, Mr. G. went to the emergency department, unable to walk

because of intense pain and swelling of his entire left leg. His blood sugar
and blood pressure were both very high, and he was admitted to the hospital
to treat his infection and control his blood pressure. During his emergency
department treatment and admission, he was examined by, and spoke to,
four different doctors.
The fifth doctor to take a history and examine Mr. G discovered that he had
taken none of his seven chronic medications, nor the newly prescribed anti-
biotic given to him when his infection first appeared. Mr. G. explained “You
see, I already take 19 pills a day, and when I got another one I got confused
about my timing, and I was just so scared I might mess up. My daughter
usually helps me with my medicines, but she’s been sick and I didn’t want to
worry her.”
167

168 HEALTH LITERACY
THE CONTEXT OF HEALTH SYSTEMS
N
avigating the U.S. health-care and public health delivery systems is
a complex task with numerous layers of bureaucracy, procedures,
and processes. Consequently, an adult’s ability or inability to navi-
gate these systems may reflect systemic complexity as well as individual
skill levels. Patients, clients, and their family members are typically unfamil-
iar with these systems and the associated jargon. Even highly educated
individuals may find the systems too complicated to understand, especially
when people are made more vulnerable by poor health. Official documents,
including informed consent forms, social services forms, and public health
and medical instructions, as well as health information materials often use
jargon and technical language that make them unnecessarily difficult to use
(Rudd et al., 2000).
When you have medical forms and stuff, I don’t think it should be compli-
cated for a person to understand what its saying (Rudd and DeJong, 2000).
Some of the complexity of the health-care system arises from the nature
of health care and public health itself, the mix of public and private financ-
ing, and the health information and health-care delivery settings. Unlike
many other countries, the United States does not have a single organized
national health-care system. Furthermore, the United States has no national
health surveillance system, and few common norms exist for basic preven-
tive services such as immunizations. Threats of bioterrorism and new emerg-
ing diseases such as SARS continue to complicate the picture of health care.
In the past, health management was primarily the domain of the phy-
sician, but greater responsibility for health management has shifted to the
patient as health care has evolved and cost pressures on care have in-
creased. This has been called self-management, and was identified in the
Institute of Medicine (IOM) Priority Areas for National Action report
(IOM, 2003b) as one of two cross-cutting issues in improving health-care
quality that present the opportunity to improve health across the lifespan,
at all stages of health service. In order to make appropriate self-manage-
ment decisions, health information consumers must locate health informa-
tion, evaluate the information for credibility and quality, and analyze the
risks and benefits, activities that rely on health literacy skills. Consumers
must be able to express health concerns clearly by describing symptoms in
ways the providers can understand. Both patients and health-care provid-
ers must be able to ask pertinent questions and fully understand the avail-
able medical information.

HEALTH SYSTEMS 169
Improvement of health literacy was identified by the IOM report as an

essential component of self-management that would affect nearly all as-
pects of health care. The IOM report further noted that system and policy
changes to improve self-management would require involvement by most
health-care organizations and providers to address all types of health condi-
tions, providing a means to improve health care for all Americans. Figure
6-1 below is a depiction of the “ecology of health service organizations”
that form the U.S. health system (Shortell and Kaluzny, 2000). This figure
illustrates the complex relationships of organizations and programs that
form the basis of the U.S. health-care system that adults are expected to
navigate.
The organizations with the most direct impact on patients are in the
inner circles and those with a more indirect influence are in the outer
circles. Although this complex system could be simplified somewhat by
consolidating some of the depicted organizations (such as hospitals and
physician groups) into a variety of health networks and health systems,
other factors deter such consolidation. For example, tightly integrated
managed care systems have failed to grow in response to consumer
demands for more choice. Accessing and using the systems effectively is
further complicated by the mix of private and public financing mecha-
nisms and interrelationships.
Individuals and families must learn how to interact with employers,
supplemental private insurance companies, federal and state government
Research
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FIGURE 6-1 The concentric ecology of organizations in the health-care sector.

SOURCE: Health Care Management: Organization, Design, and Behavior, 4th Edi-
tion, by Shortell and Kaluzny. © 2000. Reprinted with permission of Delmar Learn-
ing, a division of Thomson Learning: www.thomsonrights.com. Fax 800 730-2215.

170 HEALTH LITERACY
programs, and providers who are paid directly, “out-of-pocket.” To com-

plicate matters further, individuals seldom interact with only one aspect of
the health-care system. They make decisions about the severity of illness,
the ease and cost of various treatment options, and move from self-care to
seeking advice, from public to private options, and from primary to tertiary
care in complex “patterns of resort” (Scrimshaw and Hurtado, 1987). Yet
studies indicate that individuals and families lack the information needed
for these activities. Chapter 2 provides evidence that health literacy affects
the interaction of individuals with components of the health-care system,
and may further affect health status and outcomes. Studies suggest that
health information is often more difficult to comprehend than other types
of information (Root and Stableford, 1999). Extensive research shows that
communication of health information through printed material, multime-
dia, and interpersonal exchange is often not successful (Baker and Wilson,
1996; Berland et al., 2001; Davis et al., 1996; Graber et al., 1999;
MacKinnon, 1984; Meade et al., 1989; Meeuwesen et al., 2002; Reid et al.,
1995; Roter et al., 2001; Rudd, 2003; Rudd et al., 2000; Smith et al.,
1998). Print and interactive materials have been consistently found to be
less understandable by their audience than the authors intended (Kerka,
2000; Rudd et al., 2000). Complex materials frequently used by employers,
insurance companies, government programs, and providers, such as con-
sent forms and questionnaires, are difficult for many people to use appro-
priately (Gaba and Grossman, 2003; Hochhauser, 1997; Kaufer et al.,
1983; Morales et al., 2001; Osborne and Hochhauser, 1999).
All but the most sophisticated health policy experts have difficulty
understanding the many facets of health and health care. Most of us are
confused by our hospital and medical bills, the choices we have to make
regarding health plans and health coverage, and the often contradictory
news accounts about the most effective treatments or preventive strategies.
Imagine having to face this complexity if you are one of the 90 million
American adults who this committee has found “lack the functional literacy
skills in English to use the U.S. health care system.”1
1See Finding 3-1: “About 90 million adults, an estimate based on the 1992 National Adult
Literacy Survey (NALS), have literacy skills that test below high school level (NALS Levels 1
and 2). Of these, about 40–44 million (NALS Level 1) have difficulty finding information in
unfamiliar or complex texts such as newspaper articles, editorials, medicine labels, forms, or
charts. Because the medical and public health literature indicates that health materials are
complex and often far above high school level, the committee notes that approximately 90
million adults may lack the needed literacy skills to effectively use the U.S. health system. The
majority of these adults are native-born English speakers. Literacy levels are lower among the
elderly, those who have lower educational levels, those who are poor, minority populations,
and groups with limited English proficiency such as recent immigrants.”

HEALTH SYSTEMS 171
Finding 6-1 Demands for reading, writing, and numeracy skills are
intensified due to health-care systems’ complexities, advancements in scien-
tific discoveries, and new technologies. These demands exceed the health
literacy skills of most adults in the United States.
Emerging Issues in the Health System Context2

In addition to the general complexity of the current system, the com-
mittee has identified a number of emerging themes or issues that are impor-
tant aspects of the health system context with respect to health literacy.
These include
• Chronic disease care and self-management

• Patient–provider communication
• Patient safety and health-care quality
• Access to health care and preventive services
• Provider time limitations
• Health expenditures
• Consumer-directed health care
Each of these topics is briefly discussed in the section that follows, with
particular attention to the ways in which these issues may function as
barriers to those with limited health literacy. Other issues that are currently
salient in the health-care context include health disparities and the increas-
ingly complex health information context; these topics are discussed in
Chapter 4.
Chronic Disease Care and Self-Management

Chronic disease, and the problem of people having to cope with mul-
tiple, comorbid conditions, is a critical issue in health care, particularly as
the health-care delivery system becomes more and more complex and pa-
tients must become the integrators of their own care. Chronic disease exem-
plifies the interaction of health literacy and health, as patients’ health is
often dependent on their ability and willingness to carry out a set of health
activities essential to the management and treatment of chronic diseases
(IOM, 2002c). The last few decades have seen tremendous advances in the
2The information in this section is drawn in part from the background paper “Improving
Chronic Disease Care for Populations with Limited Health Literacy,” commissioned by the
committee from Dean Schillinger, M.D. The committee appreciates his contribution. The full
text of the paper can be found in Appendix B.

172 HEALTH LITERACY
care of chronic conditions, including an array of therapeutic options, risk

factor modification for secondary prevention of comorbid conditions, the
availability of home monitoring tools, and the growth of disease manage-
ment programs (Bodenheimer, 1999; McCulloch et al., 2000). Despite these
advances, health quality and clinical outcomes of patients with chronic
diseases vary significantly across sociodemographic lines (Fiscella et al.,
2000; Piette, 1999, 2000; Vinicor et al., 2000).
Care for those with chronic diseases is more difficult for patients, pro-
viders, and families when patients cannot understand or remember the
given directions, and or when directions that are given are incomplete and
unclear (IOM, 2003b). This is also true in other contexts, such as acute care
and public health interventions. The collaboration between patients, pro-
viders, the system of care, and the community that is required to optimize
health outcomes adds a significant layer of complexity to the delivery of
health care to individuals with chronic disease. Effective disease manage-
ment is predicated on systematic, interactive communication between a
population of patients with the disease and the providers and health system
with whom they interact (Norris et al., 2002a, b; Von Korff et al., 1997),
all occurring in the context of a supportive community whose resources are
aligned with patients’ needs (Wagner, 1995).
Chronic care involves an ongoing process of patient assessments, ad-
justments to treatment plans, and reassessments to measure change in pa-
tient health status. Without timely and reliable information about patients’
health status, symptoms, and self-care, the necessary health education, treat-
ments, or behavioral adjustments may come late or not at all, compromis-
ing patients’ health and increasing the likelihood of poor outcomes. Self-
management is essential to successful chronic disease care; patients must
remember any self-care instructions they have received from their provider,
be able to correctly interpret symptoms or results of self-monitoring, and
appropriately problem-solve regarding adjustments to the treatment regi-
men. Patients also must know when and how to contact the provider should
the need arise. A number of studies demonstrate that patients remember
and understand as little as half of what they are told by their physicians
(Bertakis, 1977; Cole and Bird, 2000; Crane, 1997; Rost and Roter, 1987;
Roter, 2000). In addition, because they have knowledge deficits, patients
with limited health literacy may be less equipped to overcome such gaps in
understanding and memory once they are at home (Williams et al., 1998a, b)
and difficulties reading or interpreting instructions (Crane, 1997; Williams
et al., 1998b). Cross-sectional studies involving patients with diabetes sug-
gest that traditional self-management education may not eliminate health
literacy-related disparities in chronic disease outcomes (Schillinger et al.,
2002; Williams et al., 1998b). Focus groups of patients with limited health
literacy have identified “health system navigation” (such as knowing whom,

HEALTH SYSTEMS 173
for what, and when to call for assistance with a problem) as a particularly
daunting aspect of chronic disease management (Baker et al., 1996).
Building on the Chronic Care Model of Wagner et al. (2001),
Schillinger has developed a framework that explores ways to improve
chronic disease care and is based on health literacy and related research.
This framework is discussed in greater detail in Appendix B, but briefly,
the model represents the evidence base for chronic disease care and sup-
ports the importance of executive leadership and incentives to promote
quality, systems to track and monitor patients’ progress and support timely
provider decision-making (Piette, 2000), patient self-management training
(Lorig et al., 1999; Von Korff et al., 1997), and community-oriented care.
Since self-management practices and clinical outcomes in chronic disease
care appear to vary by patients’ level of health literacy (Kalichman and
Rompa, 2000; Schillinger et al., 2002; Williams et al., 1998b), the Chronic
Care Model, and similar comprehensive, population-based disease man-
agement approaches, may offer insights into the ways in which limited
health literacy affects chronic disease care and could identify points for
potentially successful intervention.
Patient–Provider Communication
To Err Is Human reported that communication failure was the under-
lying cause of fully 10 percent of adverse drug events (IOM, 2000b). Man-
agement of complex drug therapies, especially in elderly patients, is ex-
tremely difficult and requires special attention to the ability of the patient to
understand and remember the amount and timing of dose, as well as behav-
ioral modifications required by the regimen (e.g., dietary restrictions) (IOM,
2000b). The patient’s health literacy level as it affects the communication
process is therefore an important consideration in health outcomes.
There is some evidence of a failure of communication with patients
with limited health literacy as currently measured. Patients with chronic
diseases and limited health literacy have been shown to have poor knowl-
edge of their condition and of its management (Williams et al., 1998a, b),
often despite having received standard self-management education. Patients
with limited health literacy have greater difficulties accurately reporting
their medication regimens and describing the reasons for which their medi-
cations were prescribed (Schillinger et al., 2003a; Williams et al., 1995) and
more frequently have explanatory models3 that may interfere with adher-
3“Explanatory models are the lenses through which cultures perceive and understand ill-
ness. They consist of interpretive notions about aspects of illness and treatment including the
cause, the timing and mode of onset of the symptoms, the pathophysiological processes
involved, the natural history and severity, and the appropriate treatment” (Kleinman, 1980).

174 HEALTH LITERACY
ence (Kalichman et al., 1999). Understanding these explanatory models is

essential to good communication regarding care (Good and Good, 1981;
Kleinman, 1980).
While, by definition, patients with limited health literacy have prob-
lems with literacy- and numeracy-related tasks in the health-care setting, a
recent study among patients with diabetes demonstrated that these patients
also experience difficulties with oral communication (Schillinger et al.,
2004). Patients appear to have particular problems with both the decision-
making and the explanatory, technical components of dialogue. Further-
more, patients with limited health literacy may be less likely to challenge or
ask questions of the provider (Baker et al., 1996; Street, 1991) and may
cope by being passive or appearing uninterested (Cooper and Roter, 2003;
Roter, 2000; Roter and Hall, 1992; Roter et al., 1997).
Health literacy is one of a number of influences on the communica-
tion process. Communication between a health-care provider and patient
during outpatient visits may also be hampered by several related factors.
These include the relative infrequency and brevity of visits, language bar-
riers, differences between providers’ and patients’ agendas and communi-
cation styles and other cultural barriers, lack of trust between the patient
and provider, overriding or competing clinical problems, lack of timeli-
ness of visit in relation to disease-specific problem, and the complexity
and variability of patients’ reporting of symptoms and trends in their
health status.
The complexities that arise from the interplay of cultural processes and
variations in health literacy underlie communications and interactions in
the health-care system. Typically this balance is part of a healing relation-
ship governed by cultural beliefs and rituals that manifest as a cultural
language. Health-care providers need to comprehend this cultural language
in order to reduce misunderstanding. Reciprocal to this understanding are
the skills of the people among the different cultural groups to understand
what health-care providers are communicating regarding their diagnosis,
risks, and treatment options.
Diverse cultural groups value distinct processes by which harmony and
balance is maintained in the relationships of everyday life. Typically this
balance is referred to as healing and along with the dynamics surrounding
human relationships, these become “healing relationships” governed by
cultural beliefs and rituals that manifest as culturally based language during
health and illness. Cultural contexts dominate healing relationships. “Phy-
sicians and other health care providers need communication skills . . . to
reduce misunderstanding and the risk of incorrect diagnosis and . . . to
develop . . . treatment plans that are compatible with the patient’s reality”
(Molina et al., 1994: 35). Reciprocal to this communication are the skills of
the people (individual, families, and communities among different cultural

HEALTH SYSTEMS 175
groups) to understand what health-care providers are discussing about di-

agnoses, risks, and treatment options. In contrast, aboriginal peoples have a
vision of healing that informs the “process of healing oneself, relationships
with families” and “maintaining balance among their mental, physical,
emotional and spiritual dimensions as human beings” (Ross, 1996: 147). In
Westernized health care, the concept of healing is typically used during
experiences with illness or disruptions in health status. In contrast, some
aboriginal cultural languages present healing as an aspect of health and
everyday living. “Instead healing is seen as an everyday thing for everyone,
something which, like sound nutrition, creates health. In short, the healing
perspective must be built into the attitudes and process that shape every
aspect of everyday” (Ross, 1996: 147).
In another example, Native Hawaiians comprehend healing through a
system for maintaining harmonious relationships and resolving conflicts
within the extended family; this system is called Ho’oponopono, which
means setting to right. The Ho’oponopono process is a conceptual frame-
work informed by several cultural concepts that become evident as the steps
in the cultural ritual. These include problem identification, discussion, seek-
ing forgiveness; release of conflicts and hurts; and the closing phase. Ho’op-
onopono is especially useful as a mental health intervention (e.g., for alco-
hol or substance abuse, domestic violence, anger) but also complements
interventions for coping with diseases.
“Then the ho’ola said Mom should confess to me and before God Jehovah.
She did. She asked me to forgive her and I did. I wasn’t angry. . . . And later
Mom’s sickness left her. Of course, she still had diabetes, but the rest—being
so confused and miserable—all that left her” (Shook, 1985: 109).
This broader humanistic perspective of healing is critical to compre-

hend aboriginal and Native Hawaiian health behaviors and to understand
the importance of healing rituals for inclusion in treatment options and
caring interventions during health and illness. These culturally based views
of health suggest a trajectory for forming healing relationships in that they
illuminate a fuller range of human experiences during health and illness.
Understanding a greater diversity of healing relationships supports health
literacy among different cultural groups. To this end, good health commu-
nications are a key pathway to building the continuous healing relation-
ships that have been cited as an important goal for twenty-first century
health-care system design (IOM, 2001). Poor communications and rela-
tionships translate into unfavorable outcomes, particularly delays in care
seeking, refusal, lack of continuity of care, and disparities (IOM, 2003a).

176 HEALTH LITERACY
Patient Safety and Health-Care Quality4

The IOM report To Err Is Human (IOM, 2000b) clarifies the links
between miscommunication and medical and health errors and adverse
events. Lack of cultural competence and inattention to health literacy can
both compromise patient safety through a number of mechanisms. For
example, a variety of problems can result if culture and language are not
taken into account including
• Failure to get accurate medical histories

• Failure to obtain informed consent
• Poor health knowledge and understanding of health conditions
• Poor treatment adherence
• Medication errors
• Lower utilization of preventive and other health-care services
• Poor patient satisfaction
To the extent that low health literacy may be more prevalent among
some racial and ethnic minority groups, these individuals may be at higher
risk for adverse events stemming from poor communication. There is a
need to understand the independent contributions of cultural competence
and health literacy to patient safety, as well as the interactions between
cultural competence and health literacy.
Patients’ varied perspectives, values, beliefs, and behaviors regarding
health and illness are consistently cited as integral to quality care in several
IOM reports (2001, 2003a). To protect people from undue harm, eliminate
errors and adverse events, prevent unnecessary human suffering, and be
more accountable to quality and cost-effective care, cultural processes
beckon attention, particularly to erode the culture of blame, reform team-
work, and redesign organizational dynamics within health-care systems. A
principle of patient safety is to include patients in safety designs and the
processes of care (IOM, 2000b). To do so, it is essential to understand
cultural nuances of what patient safety means to different people and what
beliefs, values, and actions inform people’s understanding of safe care come
into play.
The communication process plays a central role in this understanding.
For example, a recent study in California of pediatric outpatient visits that
used Spanish-language interpreters found an average of 31 interpretation
errors per pediatric clinic visit (Flores et al., 2003), two-thirds of which had
clinical consequences. The errors included errors in the dose and duration
4The committee thanks Arlene Bierman, M.D., M.S., for her contributions to this section of
the report.

HEALTH SYSTEMS 177
of prescribed drugs and missed information on patient allergies. Errors

were most common with untrained interpreters. Amoxicillin for an ear
infection was translated as one teaspoon three times a day in the ears,
rather than by mouth. Steroid ointment for a baby’s face was translated as
“rub on the body” and twice a day for three or four days was translated as
“in four days.”
In building a safer health-care system, strategies are needed to include
culture and communication, inclusive of patients and families, as an inte-
gral component of interventions to reduce medical and health errors and
adverse events like these.
The interaction of health literacy, culture, language, and safety is not
limited to patient safety. Worker safety is also influenced by health literacy.
Workers must employ safeguards against hazardous materials and proce-
dures. They are expected to read warning labels and right-to-know postings
and take important precautionary measures. Yet, for some, the information
may not accessible. The potential of low literacy and limited English profi-
ciency to affect worker safety has been noted by health and safety educators
and unions (Wallerstein, 1992). A recent National Academies workshop on
Latino worker safety (NRC, 2003) noted that Spanish-speaking workers
are four times more likely to be injured or killed on the job than English-
speaking workers. The need to improve and properly translate signage,
safety and use instructions, and training procedures is noted in that report
(NRC, 2003). Strategies suggested to improve worker safety training in-
clude participatory education and popular education approaches (e.g.,
Wallerstein, 1992). Further research in this area is critical to the develop-
ment of successful safety programs.
I prepared all my material, cut all my pieces of Formica, and I opened the
can and I didn’t really read the label. There was a red label on the can and
even if I would have looked at it, I didn’t know what it was. I couldn’t even
read it. Come to find out my lung was poisoned from that material I was
using (Rudd and DeJong, 2000).
Crossing the Quality Chasm: A New Health System for the 21st Cen-
tury (IOM, 2001) proposed that health-care processes are to be redesigned
according to 10 rules, 6 of which allude to cultural context and 5 of which
relate to health literacy via information and communications. These rules
are shown in Box 6-1. Twenty-first century health care will unravel the
complexities that arise from the interplay of cultural processes and health
literacy. Proposed changes include customizing care based on patient needs
and values and accommodating differences in patient preferences and an-

178 HEALTH LITERACY
BOX 6-1
Rules for Redesigning Health-Care Processes
1. Care based on continuous healing relationships. Patients should receive care

whenever they need it and in many forms, not just face-to-face visits. This rule
implies that the health-care system should be responsive at all times (24 hours
a day, every day) and that access to care should be provided over the Internet,
by telephone, and by other means in addition to face-to-face visits.
2. Customization based on patient needs and values. The system of care should
be designed to meet the most common types of needs, but have the capability
to respond to individual patient choices and preferences.
3. The patient as the source of control. Patients should be given the necessary
information and the opportunity to exercise the degree of control they choose
over health-care decisions that affect them. The health system should be able
to accommodate differences in patient preferences and encourage shared de-
cision making.
4. Shared knowledge and the free flow of information. Patients should have un-
fettered access to their own medical information and to clinical knowledge.
Clinicians and patients should communicate effectively and share information.
5. Evidence-based decision making. Patients should receive care based on the
best available scientific knowledge.
6. Safety as a system property. Patients should be safe from injury caused by the
care system.
7. The need for transparency. The health-care system should make available to
patients and their families information that allows them to make informed deci-
sions when selecting a health plan, hospital, or clinical practice, or choosing
among alternative treatments.
8. Anticipation of needs. The health system should anticipate patient needs, rath-
er than simply reacting to events.
9. Continuous decrease in waste. The health system should not waste resources
or patient time.
10. Cooperation among clinicians. Clinicians and institutions should actively col-
laborate and communicate to ensure an appropriate exchange of information
and coordination of care.
SOURCE: IOM (2001).
ticipating patient needs. Customizing (to match individual specifications)

and tailoring (to adapt for special needs or purpose) approaches to patient
care services are based on the assumption that understanding of people’s
needs, characteristics, and respect for beliefs and values are operating. Such
understanding and respect is rooted in patient-centered care (Gerteis et al.,
1993). Customized and tailored information, communication, and educa-
tion are integral to individualized care (IOM, 2001). To customize and
tailor care means that health literacy is subsumed within a cultural context

HEALTH SYSTEMS 179
during clinical encounters. This report also recommended that a “patient-

centered” approach be implemented to ensure that patients have full under-
standing of all of their options (IOM, 2001).
Access to Health Care and Preventive Services

Literacy and disparities are two sides common to a health phenomenon
rather than two separate problems. Data continue to emerge to support the
idea that the different needs of particular individuals and groups who have
been historically marginalized or disenfranchised due to their ethnic or
racial heritage, or social group identity or membership, continue to be
unmet by the health-care system (IOM, 2003a). Inattention to patient pref-
erences, lack of patient-centered care, and insufficient English proficiency
(written or verbal) are contextual qualities that fuel health disparities among
particular groups and individuals in the United States. In this way, limited
health literacy may be a precursor to and condition of health disparities.
Interventions to increase communications, improve access to health infor-
mation, promote the understanding of meaning from facts, and transfer
knowledge to actions are likely to reduce the negative impact of low literacy
on patients’ access and use of health services.
Health services access involves many factors. These include financial
ability to use services, lack of appropriate services located where people can
reach them, times when services are available, health-care staff’s ability to
appropriately navigate language and culture with patients, and respectful
treatment of patients. Ethnic background and minority status also influence
access to care (IOM, 2003a). Across all populations, the individuals most
likely to be dissatisfied with seeking care are members of minority groups.
These minority groups indicated they felt their race, ethnicity, and ability to
pay for services directly affected their level of care (IOM, 2002b). An IOM
report found differences in access and in treatment of patients who are
poor, African American, Latino, and American Indian, among others (IOM,
2003a). Health literacy is an additional factor that should be considered
when examining access to care and use of preventive services. Preliminary
research supports such a link. This research is reviewed in Chapter 3.
Briefly, individuals with limited health literacy as determined by the avail-
able measures are less likely to use preventive services such as mammograms
and pap smears (Scott et al., 2002), and may come to the attention of the
health-care system at a more advanced stage of disease (Bennett et al.,
1998).
A lack of health insurance and lack of access to affordable services may
lead people to postpone or not participate in care, particularly preventative
care such as screenings, but also including recommended medical tests,
treatments, and prescribed medications (Kaiser Commission on Medicaid

180 HEALTH LITERACY
and the Uninsured, 2003a). Rates of uninsurance in the United States vary
by race and ethnicity at 12 percent of Caucasians, 20 percent of Asian
Americans, 22 percent of African Americans, more than 25 percent of
Native Americans, and more than 33 percent of Hispanics (Kaiser Commis-
sion on Medicaid and the Uninsured, 2003b). Uninsured patients are more
likely to have poorer health than they would if insured (IOM, 2002a).
Many African-American women who are uninsured or underinsured put
their families’ welfare ahead of their own, especially when financial re-
sources are limited. They seek treatment too late or not at all (IOM, 1999).
Further, people who are uninsured or underinsured are more likely to rely
on emergency departments for care (IOM, 2002b). An example of this can
be seen in asthma. If someone cannot afford the appropriate workup, con-
sultation, and medications to properly control asthma, they (or their chil-
dren in the case of childhood asthma) will be less likely to prevent attacks
that may lead to emergency department use (IOM, 2002b).
The problems created by the financial inability to use services may be
exacerbated by health literacy issues, including limited knowledge and in-
formation surrounding early symptoms of serious illness and the value of
prevention. Preliminary evidence discussed in Chapter 3 suggests that these
socioeconomic, cultural, and health literacy factors may be associated with
higher costs in the long run, when expensive tertiary care and emergency
department services become necessary.
Limited local health resources and services can also impede access to
care. Grocery stores and heath services are among the many resources that
are limited in low-income and remote areas. Transportation may be a ma-
jor obstacle; if services are difficult to get to or far away, people may do
without, or postpone the use of the service. For some individuals often only
limited primary care treatment services are available conveniently. So, for
example, women needing mammograms may have to travel to a facility
where this can be done, which can be a deterrent to obtaining that service.
Limitations on hours of availability can also reduce access. Some clinics
operate only or primarily during business hours. This may create problems
for many people seeking health services. In particular, low-income patients
may have a harder time getting time off from work, or finding child care, in
order to seek care or take a family member to get care. Health services that
have weekend and evening hours could potentially help prevent the unnec-
essary use of emergency departments.
Limitations on Provider Time

A major impediment to appropriate communication about health is the
limitation on provider time that is often required by HMOs, public clinics,
and health-care reimbursement plans. For example, most plans do not

HEALTH SYSTEMS 181
reimburse for time spent in instructing patients on how to manage diabetes.

It is nearly impossible to deal with literacy, language, and cultural issues
within the context of a 10–15-minute patient visit. Ironically, the result of
poor communication and abbreviated or no patient education is higher use
of emergency services, greater severity of illnesses, failure to follow instruc-
tions and use medications properly, and other “errors” which ultimately
result in increased health-care costs.
In this regard, Linzer and colleagues (2000) have established that time
pressure is related to lower levels of physician career satisfaction, especially
in the managed care setting. Federman and others (2001) have demon-
strated that failure of physicians to acknowledge patient concerns, provide
explanations of care, and spend sufficient time with patients may contrib-
ute to patients’ decisions to discontinue care at their usual site of care.
Discussing these papers in an editorial Warde (2001) states that “it seems
that a physicians ability to engage the patient without distraction from
other activities is an important determinant in the quality of an encounter
with a patient . . . true access means being psychologically available to
conduct interviews that center on the physical, social, and psychological
needs of each patient.” She goes on to suggest that “through its effect on the
doctor–patient relationship, time pressure may diminish the very outcomes
that health plans strive to achieve: high quality of care, access, cost-effective
resource utilization, and patient satisfaction” (Warde, 2001). Encounters
with limited-literacy patients can only require more time to overcome these
barriers.
Health Expenditures
Health expenditures are of concern to decision makers in both the
public and private sectors, and particularly to private employers and small
businesses. Health spending has increased as a percentage of gross domestic
product (GDP) as growth in health expenditures has outpaced growth in
the economy as a whole. The Department of Health and Human Services
(HHS)5 projects that the increase in health expenditures will fall to about 7
percent in the 2003–2007 period, and to 6.6 percent during 2008–2011
(Heffler et al., 2002). During this period health spending will continue to
5National health expenditures and future projections are reported annually by the Office of
the Actuary in the Department of Health and Human Services. It reports on total national
health expenditures, including all services such as hospitalization, physician and dentist care,
pharmaceuticals, nursing homes, home health, and other costs; these also cover all sources of
payment such as Medicare, Medicaid, different forms of private insurance and managed care
plans, and out-of-pocket payments by individuals.

182 HEALTH LITERACY
outpace the overall economy by 2.5 percent per year, resulting in growth
from 13.2 percent of GDP in 2000 to 17 percent in 2011. There is no
reason to believe that these increases will moderate in the near term, and
policy attention from both public and private sectors will continue. This
attention has led to a renewed discussion of health-care policy as a na-
tional- and state-level issue that has included fundamental questions such as
whether health insurance should be tied to employment, the relative roles of
the public and private sectors, and whether consumers themselves should
assume more responsibility for health-care costs and quality.
The most recent national estimate of expenditures for 2001 is $1.4
trillion or $5,035 per capita, based on a growth rate of 8.7 percent in 2001
(Levit et al., 2003). These expenditures are the highest in the world. The
reasons for these high rates are complex. Although greater volume is often
cited as the primary reason for higher costs in the United States as com-
pared to other countries, it has been found that prices of services, rather
than volume, are responsible for higher costs in the United States. Adminis-
trative costs in the private sector are also much higher than in other coun-
tries or in Medicare. While some combination of new technology and in-
creased demand has led to increases in both prices and utilization, these
vary across the nation. A recent study indicates that variation in expendi-
tures between states is in part due to underlying demographics like age and
wage rates, and in part due to the supply of hospitals and physicians (Mar-
tin et al., 2002). In addition, states with higher managed care penetration
have lower expenditures. This is thought to be attributable to “both lower
premium rates charged by HMOs and spillover effects of competition on
non HMO premiums” (Martin et al., 2002).
Preliminary evidence on the cost implications of limited health literacy
(presented in Chapter 3), while not conclusive, give some idea of the mag-
nitude of impact of health literacy on national medical expenditures. Ef-
forts to improve health literacy, or to limit its detrimental effects, may
provide an important contribution to health-care policy addressing rising
health expenditures (Heffler et al., 2002; Levit et al., 2002; Martin et al.,
2002).
Consumer-Directed Health Care

A major emerging issue in the health system is increased consumer
involvement in health-care choices. This movement has evolved primarily
from self-insured employers who have developed a series of “consumer-
driven” or “consumer-directed” health plans. These plans require consum-
ers to make decisions about how they want to spend their health-care
dollars, including how much co-insurance and out-of-pocket expenses to
budget, which providers to see, and what services are really necessary

HEALTH SYSTEMS 183
(Edlin, 2002). Consumer-directed health care appears to have developed

because of the failure of both regulation and market forces to produce
satisfactory cost containment results, and a belief that providing consum-
ers with incentives can produce a more efficient and responsive system.
The Foundation for Accountability, with support from the Agency for
Healthcare Research and Quality (AHRQ), produced in June 2002 a “how-
to guide” called “Who’s in the Driver’s Seat? Increasing Consumer
Involvement in Health Care” (FACCT, 2002). This guide describes 48
different strategies currently being tried, which encompass employers
implementing disease management programs, purchasing coalitions teach-
ing enrollees about quality, health plans improving doctor–patient com-
munications, consumer organizations relying on members’ expertise to
develop communication materials, and researchers studying how people
acquire and use information to improve their health. More narrowly, much
attention is being given to health insurance vehicles which run the gamut
from flexible spending accounts, medical savings accounts and defined
contribution plans to new Internal Revenue Service-approved “health re-
imbursement arrangements” (Scandlen, 2003). Several new companies,
such as Definity and Lumenos, have formed to market new consumer-
driven vehicles (Elswick, 2003). These specific insurance products are still
too new to assess their impact and effectiveness and some are skeptical
that they will grow dramatically (Elswick, 2003).
In a broader sense, many in both the public and private sectors see
increased consumer involvement in coverage and care decisions as a major
force to improve the cost and quality issues that other approaches have not
been able to achieve. If this is the case, the burden for persons with limited
health literacy—who already face the challenges outlined in this report—
will surely increase significantly.
Finding 6-2 Health literacy is fundamental to quality care, and relates

to three of the six aims of quality improvement described in the IOM
Quality Chasm Report: safety, patient-centered care, and equitable treat-
ment. Self-management and health literacy have been identified by IOM as
cross-cutting priorities for health-care quality and disease prevention.
Health Law and Health Literacy6

Legislatures and courts are beginning to respond to the issues raised by
limited health literacy in the context of health care. Current laws require
6The committee thanks Frank McClellan, J.D., for his contributions to this section of the
report. Mr. McClellan summarized and interpreted the law in relation to health literacy for
the committee.

184 HEALTH LITERACY
health-care providers to furnish translators for patients who do not speak

English, and interpreters to patients who have seeing or hearing disabili-
ties.7 Current laws do not address the problem of patients with limited
literacy. We found only a few cases in which literacy itself was pivotal in
resolving the tort8 claim or lawsuit, two of which are discussed briefly
below.
Cases in which literacy is pivotal to the tort claim are likely to be more
common in the near future. The identification of health literacy as a cross-
cutting contributor to health services quality (IOM, 2003b) indicates a need
for legislative policies supporting health literacy as a contributor to good
health care. These policies would affect the development of common law,
which is driven by policy considerations. In this context, these policy con-
siderations are likely to be defined on the basis of what is good health care.
Each state has the power to develop its own common law or statutory law,
which, in the absence of a single national policy, may contribute to varia-
tions between states in the recognition of health literacy as a contributor to
good health care.
Two areas of health law and health care that are particularly central to
health literacy are the standard of reasonable care and the informed consent
process. It is around these areas that policy likely to affect common law
could be developed.
The Standard of Reasonable Care

When a patient suffers an injury that was either directly caused by the
health care rendered, or which could have been avoided by appropriate
health care, the injured patient (or his or her family) may consult an attor-
ney to determine whether the health-care provider is legally responsible for
the injury. In making that assessment, the attorney will examine federal and
state statutes, administrative regulations, and court decisions to determine
what the legal standard is for the particular service provided. The court
decisions, referred to as the common law, will in most instances include a
reference to the standard of reasonable care. In most circumstances, reason-
able care means care rendered in accordance with the standards of the
profession. Courts seek to determine what a prudent health-care worker
would do in similar circumstances on the evidence of professional stan-
dards. Practice standards developed by professional groups provide part of
7Title VI of the Civil Rights Act, and its implementing regulations. Americans with Disabili-
ties Act.
8A wrongful act other than a breach of contract for which relief may be obtained in the
form of damages or an injunction.

HEALTH SYSTEMS 185
this evidence; other evidence may be found in federal and state statutes and
their implementing regulations, accreditation standards of professional as-
sociations, and by-laws of hospitals.
The treating physician or nurse is held liable for an injury only where
ordinary care in accordance with the standards of the profession would
have avoided the accident, rather than as a guarantor of a good outcome.
Therefore, in most instances the professions control the standards by which
their members are judged. There are two important qualifications to the
profession’s control of the standards. First, the provider may be found
negligent if he or she has special knowledge indicating that following the
ordinary standard in the particular circumstances involved will expose the
patient to an unreasonable risk of harm. Second, in rare instances, a court
may declare that the whole profession may be found negligent for following
a practice that new information or alternatives have shown to be unduly
dangerous.
The concept of reasonable care can be applied to considerations of
health literacy in the context of health care. The case of Incollingo v.
Ewing9 provided a court opinion reflecting both the rule that a profession
(or a large percentage of it) may be found negligent, and the rule that each
physician must use his or her own personal knowledge. This case involved
a child who died as a result of suffering aplastic anemia due to the con-
sumption of a wide-spectrum antibiotic (Chloromycetin) prescribed at first
by the child’s pediatrician for a throat infection and abdominal pains, and
then renewed by a second physician after a telephone request by the child’s
mother.
The doctor who initially prescribed Choloromycetin sought to justify
his conduct on the ground that he was aware of the risk that the drug could
cause aplastic anemia and therefore made sure not to allow for a renewal of
the prescription. In his view, the child first presented to him with a throat
infection that he regarded as a major ailment. He argued that even the
plaintiff’s expert agreed that in prescribing this antibiotic he acted in the
same manner as 95 percent of the doctors in Philadelphia where he prac-
ticed. The court noted that the drug’s package insert warned that the drug
should not be prescribed for minor ailments, and the mother produced
expert testimony at trial that the child indeed had a minor ailment when the
drug was first prescribed. Consequently, the court found that the jury was
allowed to find the first doctor negligent for not using his personal knowl-
edge appropriately.
The doctor who renewed the prescription sought to defend his action
9444 Pa. 263, 282 A.2d 206 91971.

186 HEALTH LITERACY
on the ground that most doctors in Philadelphia would have prescribed the
same drug for a minor ailment at that time, based on a belief that the drug
was effective and posed a very small risk of serious harm. He acknowledged
that the package insert warned against such prescriptions of the drug, but
contended that the medical community often prescribes the drug because
the manufacturer had minimized its risks in communications directly to the
prescribing doctors. Rejecting this argument, the court emphasized that
medical custom is not always controlling, reflecting the rule that a profes-
sion (or a large percentage of it) may be found negligent. The health-care
provider must exercise reasonable care, “giving due regard to the advanced
state the profession at the time.”10
A similar view was expressed in Helling v. Carey11 (1974), in which the
appellate court declared as a matter of law that a prevailing medical custom
was negligent. A patient suffered blindness as a result of undiagnosed and
untreated glaucoma. The patient had been under the care of the physicians
for a number of years, and had never received a test of intraocular pressure.
The prevailing custom of ophthalmologists was to perform routine pressure
tests for early glaucoma only on patients who were over 40 years of age,
because the risk of glaucoma was, in their view, too small in persons under
40 to justify routine pressure tests. The court ruled that the doctors were
negligent as a matter of law, notwithstanding the evidence that they fol-
lowed the custom of their specialty at the time. Noting that a low-risk,
inexpensive test could have prevented a serious illness such as blindness in
a long-term patient who was experiencing loss of vision, the court declared
that reasonable care dictated the performance of the test.
This suggests that if future health literacy research supports the exist-
ence of associations between low-risk, inexpensive approaches to limited
health literacy and reduced morbidity or mortality, the rule that a profes-
sion (or a large percentage of it) may be found negligent could apply to the
failure to use health literacy interventions in clinical settings, including
programmatic changes in health information provision. Providers could
also be responsible when their knowledge indicated that a lack of patient
understanding would expose the patient to an unreasonable risk of harm.
The Doctrine of Informed Consent

The doctrine of informed consent, which obligates the physician to
inform the patient of the risks, benefits, and alternatives to undergoing or
10282 A.2d at 216.

1183 Wash. 2d 514, 519 P.2d 981.

HEALTH SYSTEMS 187
refusing to undergo the treatment recommended by the physician, has ex-

tensive legal and research implications when addressing health literacy.
Informed consent in health care and research. In most cases, consent forms
involve the use of structured and technical language to disclose subjects’
rights, roles, and responsibilities. They contain complex descriptions of
institutional practices, financial and insurance considerations, legal con-
cerns, advanced medical technologies, and potential risk/benefit consider-
ations. Cumulative research over the past two decades and across three
continents shows that consent forms for treatment and research are written
at a level beyond the skills of most patients involved in research (Criscione
et al., 2003; Freda et al., 1998; Goldstein et al., 1996; Gribble, 1999;
Grossman et al., 1994; Grundner, 1980; Hammerschmidt and Keane, 1992;
Hopper et al., 1995, 1998; Jubelirer, 1991; Lawson and Adamson, 1995;
LoVerde et al., 1989; Mader and Playe, 1997; Mathew and McGrath,
2002; McManus and Wheatley, 2003; Meade and Byrd, 1989; Ogloff and
Otto, 1991; Ordovas et al., 1999; Osuna et al., 1998; Rivera et al., 1992;
Tait et al., 2003; Tarnowski et al., 1990). Examples of consent form text at
different reading levels are provided in Table 6-1.
The readability of consent forms is often at a scientific level that con-
tributes to information overload, poor understanding, and misinformed
consent (Benson and Forman, 2002; Davis et al., 1994; Hopper et al., 1995;
Meade and Howser, 1992; Philipson et al., 1995; Raich et al., 2001; Reicken
and Rovich, 1982; Sugarman et al., 1998, 2002). In 2003, Paasch-Orlow et
al. (2003) reported results of a cross-sectional study of 114 web sites from
U.S. medical schools regarding their Institutional Review Board (IRB) read-
ability standards and informed consent templates. Specific readability stan-
dards were found on 61 web sites (54 percent) and were found to range
from a fifth-grade reading level to a tenth-grade reading level, while other
sites contained descriptive guidelines such as “simple lay language.” Results
revealed that informed consent text often falls short of the institutions’ own
readability standards and suggest that federal oversight is associated with
better readability. Figure 6-2 shows the difference between the readability
of informed consent forms and the readability required by the IRBs.
Furthermore, while patients who sign consent documents often report
their understanding of the research or treatment and satisfaction with the
consent process, they may not fully understand the consent given (Horng et
al., 2002; Pope et al., 2003; Vohra et al., 2003; Williams et al., 2003).
As pointed out in Chapter 1 of this report, all people (not just those
with low educational levels) are at risk for low health literacy. The in-
formed consent process brings with it particular challenges that may further
impede understanding. This is in part attributable to the inherent complex-

188 HEALTH LITERACY
TABLE 6-1 Examples of Informed Consent Text Provided by

Institutional Review Boards at U.S. Medical Schools*
Readability
Level Voluntary Participation No Direct Benefits
4th Grade† “You don’t have to be in this “There is no benefit to you from
research study. You can agree to being in the study. Your taking
be in the study now and change part may help patients in the
your mind later. Your decision future.”‡
will not affect your regular care.
Your doctor’s attitude toward
you will not change.”
8th Grade† “Participation in this study is “There is no direct benefit to you

entirely voluntary. You have the from being in this study.
right to leave the study at any However, your participation
time. Leaving the study will not may help others in the future as
result in any penalty or loss of a result of knowledge gained
benefits to which you are from the research.”
entitled.”
12th Grade§ “Your participation in this study is “There may be no direct benefit to
strictly voluntary. You have the me, however, information from
right to choose not to participate this study may benefit other
or to withdraw your patients with similar medical
participation at any point in this problems in the future.”
study without prejudice to your
future health care or other
services to which you are
otherwise entitled.”
*All the examples are taken directly from medical-school Web sites unless otherwise noted.
†The readability level is based on the Flesch-Kincaid readability scale.
‡The passage was modified to present key concepts at a fourth-grade reading level.
§The readability level is based on the Fry readability formula.
SOURCE: Excerpted from Table 1 in Paasche-Orlow et al. (2003). Copyright © 2003 Massa-
chusetts Medical Society. All rights reserved. Reprinted with permission.
ity and nature of informed consent information. But, it also relates to the
multitude of psychosocial, ethical, and situational factors that may sur-
round the clinical need for informed consent, such as hospitalization, emer-
gency heart surgery, participation in Phase I cancer clinical trial, genetic
testing, new vaccine for HIV, use of surgical placebos for Parkinson’s dis-
ease, or separation of conjoined twins.

HEALTH SYSTEMS 189
Lower Grade Level Higher Grade Level

Than Target Than Target
–8 –6 –4 –2 0 2 4 6 8
Difference between Grade Levels (actual minus target)
FIGURE 6-2 Difference between actual readability and target readability of in-
formed consent documents. Each bar represents 1 of the 61 institutional review
boards that indicated a specific grade-level target as a readability standard.
SOURCE: Paasche-Orlow et al. (2003). Copyright  2003. Massachusetts Medical
Society. All rights reserved.
A signature on a consent form is not adequate evidence that informed

consent has been obtained. In providing informed consent, a research par-
ticipant faces significant challenges, which are not adequately addressed
through standard policy procedures (Triantafyllou et al., 2002). In many
cases, patients and providers may disagree about the need for and adequacy
of consent. Patients tend to see consent as necessary more frequently than
providers, hold different views on whether true informed consent was ob-
tained, and may be less than satisfied with the amount of information
exchanged (Bray and Yentis, 2002; Cox, 2002; Gardner and Jones, 2002;
King, 2001; Mathew and McGrath, 2002; McManus and Wheatley, 2003;
Osuna et al., 2001; Schopp et al., 2003). These differences in views and
biases in information may not be recognized by the provider or patient
(Hewlett, 1996), and affect the patient’s right to self-determination12 and
self-decision,13 that is, the right to make any informed decision. Appelbaum
(1997) notes that in communicating with patients, clinicians and research-
ers often underplay the risks associated with the randomized trials, and the
benefits associated with standard care.
12Schloendorrf v. Society of New York Hospitals, 211 NY 125;105 NE 92 (1914).

13Canterbury v. Spence, 464 F 2d 772 (1972).

190 HEALTH LITERACY
“I was in my early 30s and having problems with my girl parts. I was bulging
in the vaginal area and I knew this was not normal. The doctor told me that
it would be an easy repair and could be done. The surgery was set up. On
the night before surgery, I remember having lots of papers pushed toward
me to sign. I signed them because I needed to do this. I had surgery the next
day and my recovery went very well. I had a large scar on my lower
abdomen. I went for my six-week follow-up visit and was asked by the nurse
how I was doing since my hysterectomy. No one had ever used those words
before, but I knew what they meant. I had never asked any questions. I made
the assumption that all doctors knew exactly what they were doing and had
better intelligence than me. I was too humiliated to reveal to the doctor and
nurse that I did not know what had been done to me. Communication had
broken down and failed me.”
“No one knew that I could not read well. Actually, I could read . . . but only
one word at a time. By the time I got to the end of a sentence—I had no
comprehension of what I had just read. I struggled to read. All that I read I
would read three times. I kept books in front of me so others would not find
out. I thought that if others found out, that they would think I was stupid. To
check on the spelling of a word, I would call the library (that way no one
could see me). There are many ways to hide poor reading from others.”
Personal story graciously provided by Toni Cordell, Adult Learner and Lit-
eracy Advocate, as told to C.D. Meade, September 2003.
Legal precedents. While no case directly addresses health literacy, cases

exist in which theories of negligence, informed consent, and literacy have
been brought to bear. A case that illustrates the potential issues that must
be considered when examining literacy and informed consent is Hidding v.
Williams14 (1991). The patient underwent a laminectomy that resulted in
complete loss of control of his bowel and bladder. Prior to surgery he
signed a consent form that stated that a risk of the surgery was “loss of
bodily function.” Since the patient died prior to trial his wife prosecuted his
personal injury claim and offered the only testimony from the patient’s
view regarding the consent process. She testified that although her husband
signed the form, he had only a fifth-grade education and minimal reading
skills. She read the consent form for him and did the best she could to
explain it. However, she thought “loss of function of bodily organs” meant
that he might not be able to get up and walk around right away after the
14578 so. 2d 1192, La. App.

HEALTH SYSTEMS 191
surgery. She had no idea that it meant he faced a risk of loss of control of
his bladder, and thus she did not include that information when she at-
tempted to explain the risks he was confronting. In light of this testimony
the judge, sitting without a jury, ruled that informed consent was not
obtained. The court explained:
The physician is required to disclose material risks in such terms as a
reasonable doctor would believe a reasonable patient would understand.
In order for a reasonable patient to have awareness of a risk he should be
told in lay language the nature and severity of the risk and the likelihood
of its occurrence. A bland statement as to a risk of ‘loss of function of
bodily organs’ when not accompanied by any estimate of its frequency
does not amount to understandable communication of any specific real
risk.15
The case supports the concept that a written document of a patient’s
consent is evidence that an informed consent was obtained, but is not
conclusive and can be rebutted by other evidence. Thus, while it is impor-
tant to have documentary evidence of advising a patient of risks, benefits,
and alternatives, the existence of that document does not prevent the court
from considering whether the information deemed critical to making a
meaningful expression of consent to the treatment was conveyed to the
patient by a means that was likely to enable patient comprehension. Signed
consent documents are treated in this manner in most states. Evidence that
the patient could not read or comprehend the form leaves the issue of
whether an informed consent was given to evidence regarding the commu-
nication process, such as verbal conversations, picture displays, and videos.
The same is true with respect to instructions given to the patient or the
patient’s family as to monitoring physical condition, administering medica-
tion, and so forth.
Finding 6-3 The readability levels of informed consent documents

(for research and clinical practice) exceed the documented average reading
levels of the majority of adults in the United States. This has important
ethical and legal implications that have not been fully explored.
Governmental and Agency Roles
Roles of the Federal Government

Many of the federal health agencies have programs and activities for
documenting and improving the health literacy of our nation. These agen-
15578 So. 2d at 1196.

192 HEALTH LITERACY
cies can influence the health-care and public health systems to develop and
support integrated strategies addressing health literacy and can increase the
scientific knowledge base about health literacy by fostering research and
collaboration.
In addition, the federal government plays a central role in the produc-
tion and dissemination of health-related information and the regulation of
such information from other sources. The involvement of specific agencies
such as the Food and Drug Administration (FDA) and the Centers for
Disease Control and Prevention (CDC) in these activities is described be-
low. One widely known regulatory action in this regard is the Health
Insurance Portability and Accountability Act of 1996. On April 14, 2003,
as mandated by this act and in accordance with the Office of Civil Rights
National Standards to Protect the Privacy of Personal Health Information,
a notice of privacy practices was disseminated to all consumers entering the
health-care system across the country (in hospitals, dental offices, pharma-
cies, and other health service locations).16 The law requires that this infor-
mation be “read and understood” by consumers. Printed information was
distributed in a variety of formats and languages to convey how medical
information may be used and disclosed including information relating to
treatment, payment and health-care operations, business associates,
fundraising, research, appointment reminders, treatment alternatives, ben-
efits and services, and persons involved in a patient’s care. However, the
committee observed that the text disseminated to convey this important
information varied widely in its nature, scope, and complexity. It is very
likely that the privacy documents were written above the reading level of
many Americans. Until formal evaluations are conducted, it remains un-
known how well consumers fully understand the federal regulations that
must be “read and understood” before care is provided.
We summarize here the activities of those agencies with important roles
relating to health literacy in the health system context. This is not an
exhaustive list of all federal agencies with related work, but is intended to
highlight those that either have ongoing activity in this area or show par-
ticular promise to influence the issue. Chapters 4 and 5 highlight some of
the health literacy-related activities of federal agencies in the contexts of the
educational system and culture and society, including those related to lan-
guage issues and interpretation in health care.
Office of the Secretary, Office of Disease Prevention and Health Promotion

As the lead agency for the health literacy objective of Healthy People 2010
16Health Insurance Portability and Accountability Act of 1996. http://www.hhs.gov/ocr/

hipaa/.

HEALTH SYSTEMS 193
(HHS, 2000), the Office of Disease Prevention and Health Promotion

(ODPHP) has been actively working to raise awareness about health lit-
eracy, to identify and coordinate health literacy activities across HHS, to
convene HHS agencies to work collaboratively on health literacy, and to
identify external partners. In 2000, ODPHP established a partnership with
the National Center for Education Statistics of the U.S. Department of
Education to develop the health literacy measures that are included in the
2003 National Assessment of Adult Literacy. These data represent the first
national measures on health literacy, and will be used to assess the Healthy
People 2010 objective. ODPHP has also collaborated with outside organi-
zations on health literacy by including health literacy in its Memoranda of
Understanding with several organizations, including the American Medical
Association (AMA) and the Academy of General Dentistry.
Centers for Medicare & Medicaid Services (CMS) Individuals considered

at highest risk for limited education and low health literacy are the elderly
and those with low incomes. Many are enrolled in the Medicare and Med-
icaid programs administered by the Centers for Medicare & Medicaid Ser-
vices (CMS). Medicare is a federally run health insurance plan covering
nearly 40 million people in the United States who are 65 years of age and
older, disabled, or have permanent kidney failure. Medicaid provides health
assistance to certain individuals and families with low incomes or resources,
and, in contrast to Medicare, is a state-administered program. See below
for further information on Medicaid. Both Medicare and Medicaid are
complicated and confusing programs, with health literacy issues in enroll-
ment, making choices, patient rights, and terminology (Hudman, 2003;
Scala, 2002).
Because CMS runs the Medicare program, it is directly responsible for
communication with people covered under Medicare about health insur-
ance coverage, their rights and protections in Medicare, and their health
plan options. Communication about the Medicaid program is a function of
each state, and CMS works with the states to ensure that people in Medic-
aid receive the information they need (see below for further information on
Medicaid). In both cases, CMS works to ensure that these communications
are accurate, reliable, relevant, understandable, and, to the extent possible,
culturally appropriate. One way it does so is through the provision of
agency-wide communication guidelines and training materials such as
“Writing and Designing Print Materials for Beneficiaries: A Guide for State
Medicaid Agencies.” CMS also uses consumer research and training, con-
sultation with literacy experts, and communication guidelines to develop
materials for consumers that are intended to be easy to navigate and under-
stand through format, design, and wording modifications. Consumer re-
search and testing includes target audience members with lower education

194 HEALTH LITERACY
levels, from a variety of ethnic, racial, income, and health experience back-
grounds.
The Food and Drug Administration The FDA regulates and provides in-
formation about drugs, biological products, medical and radiological de-
vices, the food supply, and cosmetics. Three general areas of FDA activity
related to health literacy are advertising, outreach, and labeling.
• Advertising. Advertising for prescription drugs is regulated by the

Code of Federal Regulations (21 CFR 202) and is enforced by the FDA.
Criteria indicate that both print and broadcast advertisements must not be
misleading, must provide balanced information about risks and benefits,
must state the major risks, and, for print advertisements, must contain a
brief summary statement of effectiveness. Broadcast advertisements also are
required to include “adequate provision” for methods to obtain more de-
tailed information, such as through a print ad, a toll-free telephone number,
or by asking a health-care provider.
• Outreach. Outreach to consumers and patients is a central activity
for the FDA. The FDA develops public service campaigns and announce-
ments, maintains web information for consumers, and carries out educa-
tional programs on specific topics. Challenges to successful consumer out-
reach at the FDA include: getting information to a wide variety of consumers
with different needs, abilities, and desires; encouraging consumers to use
the information; simplifying information without losing meaning or be-
coming too lengthy; and ensuring balance between risks and benefits (Lech-
ter, 2002).
• Labeling. The FDA approves and has legal jurisdiction over the
content of labels for prescription and over-the-counter medications as well
as biologics and medical devices. Aspects of medication labeling overseen
by the FDA include medication guides, patient package inserts, and the
standardized over-the-counter Drug Facts format. The FDA also performs
research on label comprehension and the actual use of labels by consumers,
monitors the prescription information provided to consumers by the pri-
vate sector, carries out consumer outreach, and monitors prescription drug
advertising.
An FDA regulation requires that over-the-counter medication labels be

written: “. . . in such terms as to render them likely to be read and under-
stood by the ordinary individual, including individuals of low comprehen-
sion, under customary conditions of purchase and use.”17 The sponsor or
1721 CFR 330.10(a)(4)(v).

HEALTH SYSTEMS 195
manufacturer of a medication is responsible for producing labels that com-

ply with this requirement, and may conduct label comprehension studies
that require the participants to apply the label information in hypothetical
situations. The FDA reviews the results of these studies in order to
strengthen the label, and to determine whether the medication can safely
and effectively be used without professional guidance. Participants in the
studies include individuals with “low comprehension” as required by the
regulation mentioned above. Low comprehension is typically defined as
having an eighth-grade reading level or below, and the Rapid Estimate of
Adult Literacy in Medicine (REALM) is frequently used to make this deter-
mination.
The Centers for Disease Control and Prevention As the lead public health
agency of the United States, the CDC has a central role in successfully
communicating information on health and illness to all members of the
public. The CDC identifies “Providing credible information to enhance
health decisions” (CDC, 2003) as one of the central goals of its mission.
Related to health literacy, the CDC’s focus has encompassed efforts around
plain language including training, testing and pre-testing materials, surveys,
and the provision of health information to TV shows, networks, writers,
and producers. The CDC has addressed issues of culture in several of its
programs. For example, the National Institute for Occupational Safety and
Health added a Spanish-language section to its web site in 2001, and the
National Immunization Program developed educational material for Ameri-
can Indians and Native Alaskans in 2003. Currently, CDC is redesigning its
web site based on a CDC web evaluation completed in 2002. The evalua-
tion showed that consumers looking for basic health information regarding
disease and disease prevention are the largest segment of visitors to the
CDC web site.
The National Institutes of Health The National Institutes of Health (NIH)

play the crucial role of determining federal funding for health literacy re-
search, and thus in large part set the research agenda on the topic in the
United States. Figure 6-3 shows NIH funding of health literacy over the
past 6 years.18 These data were derived from a search of the NIH CRISP
database from 1993 to 2002 using the following operands: “health lit-
eracy,” “health and literacy,” “health and readability,” and “literacy and
readability.” The grants retrieved were examined for relevance to the field
18The committee thanks Patrick Weld and K. Visnawath, Ph.D., of the National Cancer
Institute for their contributions to this section of the report. Mr. Weld and Dr. Viswanath
performed this search and analysis of the CRISP database. An expanded description of the
methods of their work can be found in Appendix A.

196 HEALTH LITERACY
50
40
Dollars in Millions
30
20
10
0
1997 1998 1999 2000 2001 2002
Year
FIGURE 6-3 National Institutes of Health grant funding over the 1997–2002
period.
of health literacy. A total of 906 grants for a 10-year period were identified,
but 229 of the grants from 1993–1996 contain missing financial data. The
figure shows the funding totals from the 565 grants that remained after
eliminating grants that were not funded, and grants for which data were
missing.
“Low-literacy” components were included in studies in cancer, child-
hood development and reading, arthritis, asthma, diabetes, HIV, mental
health, Alzheimer’s, health disparities, and studies in Spanish-speaking
populations. In addition, “low literacy” was included in seven Requests for
Applications since 2000, in studies such as Environmental Justice (spon-
sored by the National Institute of Environmental Health Sciences), Adult
and Family Literacy (sponsored by the National Institute of Child Health
and Human Development), Native American Research Centers for Health,
oral health disparities, diet and physical activity assessment, and cancer
communications.
Although the increase in funding over the past decade clearly represents
a positive trend, the amount funded by NIH for programs and projects that
examine health literacy is a small segment of the NIH budget. This amount,
which is equivalent to $20 to $50 million per year, has consistently been
less than half of 1 percent of the annual grant funding by NIH.
The Health Resources and Services Administration The Health Resources

and Services Administration (HRSA) of HHS provides both service and

HEALTH SYSTEMS 197
educational programs intended to improve access to health care, the quality

of health care, and health outcomes. HRSA’s programs serve millions of
diverse people from multiple racial and ethnic groups with differing educa-
tional levels who are frequently of low-income socioeconomic status. Edu-
cational programs provide training in interpretation, cultural competence,
and communication for health-care providers, while HRSA’s service pro-
grams provide funding and direction for health-care delivery sites across the
nation. Health-care delivery sites focused on various populations and types
of care are administered by the various bureaus of HRSA, including the
HIV/AIDS Bureau, the Bureau of Primary Health Care, and the Maternal
and Child Health Bureau. The service programs utilize community health
workers (also known as promotoras, outreach workers, or lay health work-
ers) who are lay members of the community and work in association with
the local health-care system, providing health education, interpreting health
information, and assisting in obtaining access to services.
Agency for Healthcare Research and Quality The AHRQ is the part of
HHS that sponsors, carries out, and disseminates research on health-care
quality, medical errors and patient safety, health-care cost, and health dis-
parities. AHRQ recently sponsored an evidence-based review of health
literacy research to answer the following questions:
• What is the relationship between literacy and health outcomes, use

of health services, and resources?
• What is the relationship between health literacy and racial dispari-
ties in health and health care?
• What are effective interventions to reduce the impact of health
literacy?
• What are effective literacy-related interventions for reducing racial
disparities in health and health care?
Although the results of this project were not available at the time
of publication of this report, AHRQ worked with the IOM to provide
preliminary information that was valuable in informing the work of the
Committee.
The Department of Veterans Affairs The Department of Veterans Affairs

(VA) is responsible for providing federal benefits, including health care, to
the nation’s veterans and their dependents. The VA’s National Center for
Health Promotion and Disease Prevention (NCP) uses patient education
and health promotion techniques in order to increase quality of life and
reduce health-care costs. The VA patient population is a vast heterogeneous
group—6 million “enrolled” veterans, and over 25 million “eligible” vets.

198 HEALTH LITERACY
They span all races, numerous cultures, all levels of education, all socioeco-
nomic strata, and both genders, with approximately 85 percent males. The
VA patient population also shows a wide age range of 18 years and up,
with two basic spikes—20- to 30-year-old veterans with short military
stints, and those over 50 years, representing retired military. The heteroge-
neity of the population points to the need for awareness of differences in
attitudes, perceptions, and level of technological adeptness. Disabilities in
the veteran population (including blindness, deafness, and mental disor-
ders) also present barriers to access and communication. The NCP uses
various techniques to ensure that educational and health promotional ma-
terials respond to all of these issues and needs.
Roles of State Governments

State governments have also identified health literacy as a critical issue.
In 2002, the Council of State Governments undertook a national research
project with the goals of (1) gathering data from the latest findings on
health literacy, (2) determining what states are doing to make it easier for
someone with low health literacy to navigate the health-care system, and
(3) preparing a report providing information and tools necessary for state
leaders to determine what appropriate action they might take. They sent a
National Survey on Health Literacy Initiatives to state governor’s offices,
departments of heath, Medicaid and State Children’s Health Insurance
Program offices, departments of education, and offices of heath literacy.
This resulted in a 2002 publication, The State Officials Guide to Health
Literacy (Matthews and Sewell, 2002).
The most important finding from this survey is that health literacy is an
emerging issue that few states have addressed specifically and directly. They
report that while no state is addressing health literacy in a comprehensive,
multifaceted manner, individual agencies in a handful of states—including
Georgia, Illinois, Massachusetts, and Virginia—have established programs,
hired staff, or created task forces to respond to low health literacy and its
effects on health-care delivery. A number of states are involved in activities
that make it easier for someone with low health literacy to navigate public
assistance programs—such as simplifying enrollment materials and proce-
dures—or to increase health literacy by setting health education standards
in both K-12 and adult literacy classes. Examples of some of these efforts
are discussed further below in the section on approaches to health literacy.
As discussed briefly above, Medicaid, the health-care assistance pro-
gram for low-income individuals and families, is a state-run program. Each
state sets its own guidelines for eligibility and services for Medicaid, under
the general guidance of CMS. As reviewed in Chapter 3, individuals with
lower income or resources are more likely than those with higher incomes

HEALTH SYSTEMS 199
or resources to have limited literacy skills. Those enrolled in Medicaid,

therefore, may be more likely to encounter barriers to care related to health
literacy. Box 6-2 discusses the differences across states in dealing with
health literacy and related issues in contracts with managed care providers
of health care to those enrolled in Medicaid.
Roles of Regulatory Agencies

There are two main private organizations in the United States for ac-
creditation and review of health-care facilities and providers: the Joint
Commission on Accreditation of Healthcare Organizations (JCAHO) and
the National Committee for Quality Assurance (NCQA).
Joint Commission on Accreditation of Healthcare Organizations The pri-

vate, nonprofit JCAHO is the oldest and largest health accreditation orga-
nization in the United States, providing accreditation to over 17,000 orga-
nizations including hospitals, health-care networks, home care agencies,
and nursing homes. Its mission is “to continuously improve the safety and
quality of care provided to the public through the provision of health care
accreditation and related services that support improvement in health care
organizations” (JCAHO, 2003). JCAHO approaches health literacy through
its standards on patients’ rights and on patient and family education and
responsibilities. These standards include assessing patient and family in-
volvement in care and care decisions, the informed consent process, and
hospital patient education tailored to patients’ assessed needs, abilities,
learning preferences, and readiness to learn. Compliance with these stan-
dards is assessed through document review, staff interviews, and review of
patient complaints. However, it is not clear how effective these standards
are in improving organizational performance regarding health literacy is-
sues, and significant changes in this process are planned for 2004.
National Committee for Quality Assurance NCQA is a private, not-for-

profit organization dedicated to improving health-care quality, best known
for its work in assessing and reporting on the quality of the nation’s man-
aged care plans through their accreditation and performance programs.
NCQA identifies health literacy as a critical step in ensuring patient partici-
pation in their health care. Testimony to the Committee from NCQA indi-
cates that thus far it has been unable to create a valid and reliable measure
that is feasible to apply at either the health plan or provider level. Such a
measure is critical in trying to hold health-care providers and insurers
accountable for both initial health literacy and improvement in health lit-
eracy (personal communication, L. Gregory Pawlson, M.D., M.P.H.,
NCQA, June 13, 2003). Regardless, there are a few provisions related to

200 HEALTH LITERACY
BOX 6-2
State Medicaid Managed Care Contracts
Information from the Center for Health Services Research and Policy’s database
on Medicaid managed care contracts (Rosenbaum et al., 2001) indicates that
guidelines and requirements for Medicaid managed care providers vary across the
states. Language in medicaid managed care contracts, valid as of 2001, shows
that although a number of states’ contracts do address some literacy- and lan-
guage-related issues, there are no specific requirements related to health literacy
in any state, and many states do not address these issues at all or do so inconsis-
tently.
Among the 42 states with risk contracts that are captured in the Medicaid Managed
Care database, 33 states and the District of Columbia included in their Medicaid
managed care contracts some type of requirement pertaining to the provision of
easily understood information. There is a great deal of variability across the states
in how this is defined, and the method of determining if the requirement is being
met. Notably, in most states, the requirement refers to the understanding of written
material only. An exception is California, which requires that both verbal and writ-
ten information be provided in a manner that can be easily understood.
In some cases, the Medicaid managed care contract includes general language
about patient comprehension such as the statement in the Massachusetts Medic-
aid Contract that requires that “written information…[be provided]…in a format and
manner that is easily readable, comprehensible to its intended audience…” (Ros-
enbaum et al., 2001). Frequently, states indicate that written information must be
readable at a specific reading grade level (see Chapter 2 for a discussion of read-
ing grade levels). The reading grade level indicated varies significantly across
states, ranging from as high as grade 8 in Montana and North Dakota, to grade 4
in a number of states, to a less-specific “suitable reading comprehension level” in
Maryland. Still other states require that “plain language” be used. Overall, a sixth-
health literacy issues that are currently part of the NCQA standards for
managed care organizations, such as:
• Quality Improvement Standard 4, which determines whether the

organization assesses the cultural, ethnic, racial, and linguistic needs of its
members and adjusts the availability of practitioners within its network, if
necessary.
• Patient Rights and Responsibilities 4, which assesses whether the
organization provides translation services within its member services tele-
phone function based on the linguistic needs of its members.
In addition, there is an indirect assessment of clinical function in the Con-

sumer Assessment of Health Plan Survey. This survey includes a query

HEALTH SYSTEMS 201
grade reading level is the most frequently cited requirement among the states that
mention a reading level.
A related issue is that some of the information provided to patients must be provid-
ed “as written” in federal law, and Medicaid managed contracts may specifically
exclude such language from requirements to be easily understood. For example,
in Texas, patient information about advance directives is excluded from its general
readability requirement since certain language is required by federal law.
Methods to determine readability level or whether information is easily understood
also vary across states. Some states name specific programs, indices, or tests that
must be used to determine reading grade level; these include methods such as the
Fry Readability Index, Flesch Scale Analysis, or the McLaughlin Simplified Mea-
sure of Gobbledygook Index. Other states’ contracts simply state the desired read-
ing grade level. Some states require that the managed care organization itself
determine if its patient information meets the requirements, while in other states
this task is reserved for the state or its designee.
Clearly, much of this language such as that referring to the intended audience
implies that attention should be given to individuals who do not speak English or
who speak English as a second language, but less frequently is this explicitly stat-
ed. A few states do, however, require that information be provided in the other
languages when the minority-language group makes up greater than 10 percent of
the population. However, contracts more frequently include provisions for transla-
tion services and cultural competence. The Medicaid managed care contracts of
12 states do not include a requirement for services to be provided to persons
whose primary language is not English. Although 25 states include a requirement
that Medicaid managed care providers must insure cultural competence, only 10 of
these states explicitly define what is meant by cultural competence.
NOTE: The information presented in this section was obtained from Rosenbaum et al. (2001).
which asks whether the member looked for any information about how a
health plan works in written materials or on the Internet, and asks how
much of a problem, if any, it was to find or understand this information.
OPPORTUNITIES IN HEALTH SYSTEMS

The understanding that no one size fits all is fundamental to the under-
standing of health literacy. There is not a simple solution to a complex
problem. Determinants and approaches for health literacy are complex,
dynamic, and require unique know-how, strategic thinking, and under-
standing of the audience. While we have stressed the importance of contri-
butions of three contexts (the educational system, culture and society, and
the health system) for improving health literacy, in Finding 2-1 we highlight

202 HEALTH LITERACY
that the health-care system “carries significant opportunity and responsibil-

ity to improve health literacy.” This section explores options for how the
health-care system can approach this responsibility to limit the negative
impact that limited health literacy has on health care and health outcomes.
The strategies discussed in this section are based on current knowledge
of interventions for limited literate individuals in health-care settings and
on the small but growing evidence about how health literacy might be
affected by various interventions. There are a few examples of interventions
specifically designed to incorporate health literacy into health systems, and
some information is available from the literature regarding interventions in
other related fields such as health communication and health education.
However, scientific investigation of interventions to minimize the impact of
limited health literacy and promote the development of health literacy skills
in the context of the health-care system is in its infancy. Conclusions about
the success of health literacy programs based on these areas should be made
cautiously. Research to evaluate the efficacy of these interventions is needed,
and the committee’s discussions represent the present consensus of experts
in the field.
Overview of Current Efforts

There are limited systematic approaches to health literacy and some of
the organizations addressing health literacy are not based in academic insti-
tutions. It is important to be aware of approaches not yet evaluated or
published in the peer-reviewed literature. Therefore, the committee com-
missioned an overview of approaches to health literacy currently being used
in the United States that have not appeared in the peer-reviewed litera-
ture.19
The commissioned authors conducted a survey of organizations that
“could make a difference” with health literacy. The types of organizations
were identified first, and then the individuals most likely to be aware of
health literacy issues and activities in that organization were contacted. The
survey was a 5-minute, 15-question, web-based survey based on a previous
survey to assess health literacy activities at the state level (Matthews and
Sewell, 2002).
Information collected included: whether health literacy is considered in
program development and service activities; the degree to which organiza-
19The committee thanks Terry Davis, Ph.D.; Julie Gazmararian, M.P.H., Ph.D.; and Estela
Marin, M.A., for their contributions to this section of the report. Drs. Davis and Gazmararian
and Ms. Marin designed, carried out, and analyzed the survey. An expanded description of
the methods of their work can be found in Appendix A.

HEALTH SYSTEMS 203
tions follow health literacy principles in their programs; target audience(s)

for activities; whether organizations pilot test materials for comprehension
or cultural competence; evaluation of materials; which activities people
associate with health literacy and lessons learned. Of the 101 individuals e-
mailed, completed surveys were received from 95 individuals from a variety
of government agencies, public and private interest groups, as well as re-
lated business groups.
Eighty-one percent of respondents indicated that they consider health
literacy in their program development and service activities. Almost all of
the respondents associated health literacy with “comprehension” (94 per-
cent) or “clear language” (92 percent). The majority associated health lit-
eracy with “cultural competence” (80 percent), “no jargon” (72 percent),
or “readability testing” (71 percent) and “self-management” (67 percent).
In addition to the pre-coded categories, respondents had the opportunity to
provide other areas they associated health literacy with. A few other topics
identified included issues of autonomy, empowerment, decision-making;
patient safety and error reduction; numeracy and computation; provider
responsibility for patient understanding; and quality of care. Table 6-2
TABLE 6-2 Frequency of Doing Health Literacy-Related Activities

Don’t No
Regularly Sometimes Do not do know response
Simplify language and

check readability 77% 18% 2% 0 3%
Reformat materials to
make them more
user-friendly 74% 19% 3% 0 4%
Confirm patient/client
understanding 50% 25% 17% 3% 5%
Train agency, staff, or
health-care providers
about health literacy 46% 32% 14% 2% 6%
Use audiovisual aids 44% 36% 14% 1% 5%
Provide materials in
multiple languages 43% 30% 18% 3% 6%
Use pictographs,
cartoons, etc. to
instruct and inform 39% 40% 19% 0 3%
Test for reading levels
in clients 25% 20 (21%) 42 (44%) 5% 4%
Use interactive
computer or kiosk 16% 25 (26%) 45 (47%) 7% 3%
NOTE: Respondents could select more than one activity.

204 HEALTH LITERACY
summarizes the type of health literacy activities that respondents reported

they or their organization were involved in. Almost 95 percent of respon-
dents indicated that they simplified language and checked readability, and
93 percent indicated that they reformatted materials to make them more
user-friendly either regularly or sometimes. Minority (e.g., Hispanic, Afri-
can American, etc.) and low-income populations were the primary target
group for these health literacy activities.
It is important to view the information gained from this survey with
caution. The survey was sent to a limited number of organizations and
individuals. The respondents are not generally representative of their re-
spective organizations. Some of the nonrespondents may have wished to
avoid confusion between personal opinion and institutional goals and
policy, avoiding the possibility that their response would be interpreted as
an institutional statement of policy rather than a personal view.
Approaches to Health Literacy in the Health System

Given the newness of the field, it is not surprising that little empirical
work exists at this time. Much more needs to be done to provide solid
guidance to all stakeholders for the most effective interventions in a variety
of settings. However, as the survey above indicates, many different ap-
proaches that show promise are currently being tried; such innovations
need to be encouraged and evaluated. In this section, we review different
categories of approaches, look at some of the studies that have evaluated
such approaches, consider what is already known about that approach
from other fields, and showcase a number of promising efforts that are
examples of the kind of work being done in this field.
For heuristic purposes, we have structured the following discussion
around six categories of interventions under which most efforts appear to
fall. These categories are as follows:
• Provision of Simplified/More Attractive Written Materials

• Technology-Based Communication Techniques
• Personal Communication and Education
• Combined Approaches
• Tailored Approaches
• Partnerships
In addition, it is important to note that training of educators and

providers is one of the most important areas of current activity in the health
literacy field. Because training cuts across nearly all of the intervention

HEALTH SYSTEMS 205
categories above, we have chosen not to break it out as a separate area, but
will mention particularly notable efforts in this area where appropriate.
Table 6-3 summarizes results from a sample of studies that have exam-
ined interventions taking place in, or sponsored by, health-care organiza-
tions. They are organized into the categories listed above, although we
acknowledge that there is necessarily some overlap among categories with
some types of interventions. These studies were gleaned from a review of
the database on health literacy performed by Michael Pignone and col-
leagues as a commissioned project for AHRQ,20 as well as from recently
published abstracts and testimony. This selection of studies was chosen to
represent an array of various types of interventions in different populations
and is not intended to be comprehensive. Studies included here did not have
to measure the literacy level of participants. Overall, the studies displayed
in Table 6-3 reflect the early state of the field. Pignone and colleagues
evaluated the strength of the available evidence for health literacy interven-
tions as part of the above-mentioned project for AHRQ (Pignone, 2003).
The four criteria used to determine reliability were (1) the study was ran-
domized, (2) the study design minimized confounding, (3) literacy was
measured, and (4) the result of the intervention was reported by literacy
level.
Five of the studies in Table 6-3 have been identified by Pignone (2003)
as the most methodologically reliable of those that have been published
(Davis et al., 1998b; Meade et al., 1994; Michielutte et al., 1992; Murphy
et al., 2000; Wydra, 2001). Wydra and colleagues (2001) found that their
interactive videodisc intervention increased reported self-care ability among
cancer patients, but that the literacy level of the patients had no effect on
this increase. Meade and colleagues (1994) examined the effectiveness of
conveying information about colon cancer via videotape versus a printed
booklet. Compared to controls, participants receiving any information dem-
onstrated increased knowledge, but the difference between the two modes
of communication was not significant. Davis and colleagues (1998b) found
that those with the lowest literacy levels, after receiving a simplified and
more appealing brochure, did not show a similar increase in comprehension
similar to those with higher literacy skills. In contrast, Michielutte and
colleagues (1992) also provided two different brochures—one with text
and one illustrated—and found that even while two brochures had no
influence on comprehension in the total research sample, those in the low-
est literacy levels showed increased comprehension with the illustrated for-
mat. It is possible that a larger sample would show a different effect.
20The committee would like to thank AHRQ for its assistance with this segment of the
report.

206 HEALTH LITERACY
TABLE 6-3 Samples of Published Studies of Interventions in

Health-Care Settings
Provision of Simplified/More Attractive Written Materials

Davis et al., Private and Nonrandomized n = 183
1998c university trial 53 patients with cancer or
oncology another medical
clinics, and a condition and 130
low-income apparently healthy
housing participants
complex
Davis et al., Three pediatric Randomized n = 610

1998b care facilities controlled trial Parents bringing children
in Louisiana to pediatric care facility
Eaton and Outpatient clinic Randomized n = 108

Holloway, at Veterans controlled trial Outpatients who could
1980 Administration read English, see normal
hospital in size type, and were not
Minneapolis, receiving warfarin
MN therapy
Hussey, 1994 Geriatric Controlled trial n = 80

outpatient (nonrandomized) Patients of clinic 65 years
clinic in a or older with at least
county one chronic health
hospital in the problem, and either of
southwestern low socioeconomic status
U.S. or indigent

HEALTH SYSTEMS 207
Simplified informed consent form Participants preferred simplified form over the
versus standard form. SWOG form, and 97% thought the simplified
69 participants given Standard form was easier to read than the SWOG form
Southwestern Oncology Group (p < 0.0001). However, there was no
(SWOG) consent form (16th grade significant difference in degree of
level) and 114 participants given understanding of the two forms.
simplified form (7th grade level)
developed for study.
Polio vaccine information brochures: Overall, readers of LSU brochure showed

304 parents received simplified significantly higher comprehension (65% vs.
LSU version, 306 received CDC 60%, p < 0.01); however, comprehension for
version most items did not achieve clinical
significance and parents in the two lowest
reading levels did not demonstrate increased
comprehension with the LSU brochure. LSU
brochure was preferred over CDC version.
Patient drug information guide Comprehension was greater for 5th-grade-level

about warfarin written at either information compared to 10th-grade-level
5th- or 10th-grade reading levels. information (p < 0.001), and for patients
with a higher reading ability compared to
those with a lower reading ability (p <
0.001). Reading ability explained 24% of
variance and grade level of materials
explained 8% of variance. Participants’
perception of level of difficulty,
understandability, and clarity of the material
was more favorable for the group receiving
the 5th-grade material as compared with
those receiving the 10th-grade material.
Color-coded method to increase Significant increase in knowledge in both

medication compliance. Group 1 Groups 1 and 2 (p < 0.001), with no
received verbal teaching about difference between the groups in knowledge
medications only; Group 2 increase. Significant increase in compliance in
received verbal teaching and both Groups 1 and 2 (p = 0.007), with a
color-coded medication schedule. greater increase in compliance for Group 2
(color-coded schedule) among those with low
compliance scores at baseline.
Continued

208 HEALTH LITERACY
TABLE 6-3 Continued

Jacobson et al., Ambulatory Randomized n = 433

1999 clinic at Grady controlled trial Primary care patients that
Memorial had not previously been
Hospital, vaccinated, and had one
Atlanta, GA of the following:
diabetes, heart failure,
other chronic illness, 65
years or older
Michielutte A private family Randomized trial n = 217

et al., 1992 practice and Women age 18 or older
three public Women who reported no
health clinics ability to read or who
—OB/GYN, reported “serious illness”
family were excluded
planning, and
sexually
transmitted
diseases
Powell et al., Pediatric clinic at Prospective cohort n = 66 families

2000 Northwestern Parents of children 6 years
University or younger who obtained
Medical primary care from the
Center, clinic
Chicago, IL
Technology-Based Communication Techniques

Kim et al., Urology clinics Uncontrolled trial n = 30
2001 in two VA 100% male
hospitals in
Chicago
Meade et al., Cancer clinic Randomized trial n = 1100

1994

HEALTH SYSTEMS 209
Low-literacy (below 5th-grade) Intervention group significantly more likely

handout to increase patient– than control group (p < 0.001 for all
physician dialogue about variables) to discuss vaccine with clinician, to
pneumococcal vaccination and receive vaccine, to show brochure to
increases rates of immunization. clinician, and for the clinician to recommend
Intervention group received vaccine. When adjusted for race, sex, age,
handout encouraging patients to education, health status, insurance status,
“ask your doctor about the clinician training, and vaccine indication,
pneumonia shot” and control intervention group significantly more likely
group received a low-literacy than control group (p < 0.001 for all
handout about nutrition. variables) to discuss vaccine with clinician
and to receive vaccine.
Cervical cancer information No difference overall in comprehension with the

brochures: 112 women received two brochures. When results were analyzed
illustrated brochure, 105 received by reading level, the illustrated brochure was
nonillustrated version. better comprehended by lower literacy
patients.
Injury prevention information No significant differences in caretaker recall of

provided by pictorial anticipatory injury prevention information assessed by
guidance (PAG) sheet requiring telephone 2–4 weeks later.
limited reading skills or TIPP
(The Injury Prevention Program).
Evaluate the knowledge, satisfaction Satisfaction with information and likelihood of

level, and treatment preferences following treatment preference not
of men newly diagnosed with significantly different by literacy or
prostate cancer after intervention educational background.
of CD-ROM about prostate
cancer.
Colon cancer information presented Participants receiving any intervention showed

in printed and videotaped increased knowledge compared with controls
formats. Subjects received either a (booklet = 23% and videotape = 26%, no
booklet, viewed a videotape, or intervention = 3%).
received no intervention.
Continued

210 HEALTH LITERACY
TABLE 6-3 Continued

Murphy et al., Sleep clinic at Controlled trial n = 192 (20 of which were
2000 Louisiana State (nonrandomized) caregivers)
University Patients at sleep clinic 18
Health Sciences years or older
Center If younger than 18,
caregiver participated
Pepe and Urban health Uncontrolled n = 20

Chodzko-Zajko, department in trial Low-income, inner-city
1997 the Midwest adults aged 60–80
Wydra, 2001 Four Randomized trial 86 intervention patients,

comprehensive 88 controls
cancer centers Patients over age 18 who
were receiving outpatient
cancer treatment
Those with less than 5th-
grade reading level or
brain or visual
dysfunction were
excluded
Personal Communication and Education

Mulrow et al., Diabetes clinic in Randomized trial n = 120
1987 London Patients with diabetes who
were overweight and not
taking insulin
Patients with a history of
diabetic ketoacidosis,
diabetes onset prior to
age 29, or over the age
of 70 where excluded.
Paasche-Orlow, Two urban Uncontrolled n = 80

2003 medical Adults hospitalized for
centers asthma exacerbation

HEALTH SYSTEMS 211
Information about sleep apnea from Short-term knowledge about sleep apnea was
an instructional videotape or a less accurate for those with reading levels less
simple brochure. than 8th grade than for those with reading
levels at or above 9th grade. Video
intervention significantly improved only two
areas of knowledge for readers below grade 8
(p < 0.05).
Cholesterol information videotape Increase in cholesterol knowledge score from

shown on follow-up visit. baseline (62%) to two-week follow-up after
videotape (77%). 6 week follow-up scores at
72%.
Change in time in cholesterol knowledge was
not significantly different between reading
groups.
Interactive videodisc program Intervention patients reported greater self-care

designed to improve self-care with ability after the intervention (p < 0.0001).
respect to fatigue symptoms for Literacy level did not affect the amount of
patients with cancer. self-care ability gained (p = 0.31).
Education program for patients with No statistically significant differences in change

non-insulin-dependent diabetes to in HbA1C levels within or between groups at
improve and sustain glucose and either 7 or 11 months.
weight control. Subjects were Differences in weight change were significant
assigned to (1) monthly group (p < 0.05) at 7 months but no change at 11
sessions with videotapes for months.
diabetic persons with low literacy No significant change in knowledge score with
skills; (2) monthly group sessions intervention.
without videotapes; or (3) no
monthly sessions after first
introductory section like Group 2.
One-on-one oral and written After instruction, about 1 in 3 high-risk adults

intervention at discharge covering required additional instruction about
medication schedule and metered medication regimen. Higher acute care
dose inhaler technique utilization, not low health literacy, predicted
the need for additional instruction.
Continued

212 HEALTH LITERACY
TABLE 6-3 Continued

Rothman et al., University-based Randomized trial n = 206

2003 general Patients with diabetes and
internal poor glucose control
medicine
practice
Schillinger Two primary Uncontrolled n = 74

et al., 2003b care clinics in trial Patients with type 2–
San Francisco diabetes mellitus
Combined Approaches
Davis et al., Public hospital in Randomized n = 445

1998a Shreveport, LA controlled trial Women 40 years old or
over, attending
ambulatory or eye clinic,
and no mammogram in
the past year
Tailored Approaches
Hayes, 1998 Emergency Randomized trial n = 60
departments, Elderly emergency room
Midwestern patients
rural area

HEALTH SYSTEMS 213
Comprehensive disease management Literacy levels predicted improvement in

intervention. glucose control among a control group with
usual care, but not among the intervention
group in the disease management program.
A measure of the extent to which Higher health literacy and physician application
physicians assess patient recall of interactive communication strategy were
and comprehension in a public associated with good glycemic control (p <
hospital setting. 0.01).
3 different interventions to increase At 6 months after intervention, Group 3

mammography usage. Group 1: showed significant increase (p = 0.05) in
personal recommendation from mammography utilization as compared to
one of the investigators. Group 2: Groups 1 or 2. This increase was no longer
recommendation and easy-to-read significant at 2 years. In a multivariate
National Cancer Institute analysis with age, race, literacy and
brochure. Group 3: mammography knowledge at baseline, the
recommendation, brochure, and only significant predictor of mammography
12-minute interactive educational use at 6 months was the Group 3
and motivational program, intervention.
including video based on focus
groups from the target population.
Comparison of the level of reading Intervention group did better on Knowledge of

knowledge from either preprinted Medication Subtest (p = 0.05).
discharge instructions (control) or
individualized computer generated
discharge instructions
(intervention). Contacted by
telephone for follow-up interview.

214 HEALTH LITERACY
Provision of Simplified/More Attractive Written Materials

Most of the approaches to improving health literacy that the committee
has encountered involve producing patient information materials that are
written with simplified language, have improved format (for example, more
white space and friendlier layout), or use pictograms or other graphic de-
vices (see information from survey above). It should be recognized that
although creating patient information at readability levels that match pa-
tient and family reading levels may achieve limited positive patient out-
comes, it may not achieve improved comprehension in all situations. For
example, while simplification of informed consent information resulted in
less intimidation (Davis et al., 1998c) and lower consent anxiety and higher
satisfaction (Coyne et al., 2003), it did not improve patient comprehension.
An example of an effort in this category is a project of the Geriatrics Section
at the University of California–San Francisco that is seeking to increase the
accessibility of advance directives to individuals with limited literacy skills.
An advance directive form has been developed that incorporates culturally
appropriate text-enhancing graphics appropriate for individuals with lim-
ited literacy skills. The form, available in both Spanish and English, not
only describes what an advance directive is, but also walks patients through
the process of filling out the form. It is written at a fifth-grade reading level
and is currently being pilot tested and compared to other standard advance
directive forms.
Graphics and other visual devices (also referred to as pictograms) are
often used to replace or supplement text in health information communica-
tions. Pharmacies or patient educators may use pictograms as part of pa-
tient education handouts, or as stickers to be placed on prescription medi-
cation packaging. These types of uses are not considered part of the official
packaging, and thus are not regulated by the FDA. Concerns have been
expressed that some of the pictograms currently in use do not accurately
convey the intended information (Rother et al., 2002). They may be open to
interpretation, and interpretation may vary by an individual’s background
and experiences. Pictograms are thought to be particularly beneficial for
communicating information to consumers who speak English as a second
language and to those with lower reading ability levels (USP, 2003). How-
ever, research suggests that individuals with limited health literacy may
have particular difficulties correctly interpreting pictograms (Price et al.,
2003). A research projected funded by Pfizer, Inc. entitled “Pictograms: A
Tool for Enhancing Health Care Outcomes Among Underserved Patients in
Primary Care?” is currently examining whether pictograms affixed to medi-
cation bottles enhance long-term recall of medication knowledge in patients
identified as having difficulty with their medications; however, no data are
as yet available from this 200-patient study. The nonprofit organization

HEALTH SYSTEMS 215
Take 4 times a day, with meals and at bedtime. This medicine may make you drowsy.
Take by mouth. Store in refrigerator.
FIGURE 6-4 Examples of pictograms for patient education.

SOURCE: United States Pharmacopeial Convention, Inc. Reprinted with permis-
sion. Copyright © 2004 United States Pharmacopeial Convention, Inc. All rights
reserved.
U.S. Pharmacopeial Convention, Inc. (USP) maintains a free library of 81

pictograms that may be downloaded from the Internet. Figure 6-4 shows
several examples of pictograms from the USP pictogram library.
Guidelines, templates, and tools are available that inform investigators
and clinicians about ways to rewrite consent documents and other commu-
nications so that they are easier to understand. For example, Philipson and
others (1999) evaluated a writing improvement intervention program imple-
mented at Hartford Hospital to help the research writer produce more
comprehensible informed consent documents and determined that the pro-
gram increased the percentages of consent documents that were readable
and at the target reading grade level. The National Cancer Institute (1998)
has prepared a set of templates and recommendations for the development
of easy-to-understand informed consent documents for cancer clinical trials
that are available online and were distributed to IRBs, hospitals, cancer
centers, patient groups, and researchers. These templates are currently in
use among cooperative cancer clinical trial groups across the United States.
While such guidelines and tools are helpful aids, solutions must also sup-
port changes in policies at the institutional and national level and become
part of ongoing federal regulatory and monitoring activities of local com-
pliance and IRBs. Box 6-3 displays two versions of an informed consent
document: the original and simplified versions.
Technology-Based Communication Techniques

A number of the interventions displayed in Table 6-3 tested the effec-
tiveness of technology-based communication techniques such as videos,

216 HEALTH LITERACY
BOX 6-3
Example of a Consent Form for Participation in
Smoking Cessation Study
Original Consent Document

Women are being invited to participate in a research in-
vestigation to determine the efficacy of two methods of
assisting pregnant women in their smoking cessation at-
tempts. A comparison of the effectiveness of educational
media in combination with a counseling method on smok-
ing habits is being examined. It cannot be guaranteed
that women may personally benefit from this investiga-
tion, but in some instances, the knowledge gained might
be beneficial to others. It is important to recognize that
participation in this study is entirely voluntary. Individu-
als may withdraw from the study at any time without pen-
alty or loss of benefits to which they are otherwise enti-
tled. Such withdrawal will not compromise any individual’s
ability to receive medical care at this institution.
Revised Simplified Consent Document
Introduction
You are being asked to take part in a
study that looks at ways to help pregnant
women stop smoking. We want to know
if booklets can help you to stop smoking.
We also want to find out how nurses can
help you to stop smoking. We cannot be
sure that this study will help you, but it
may help others. Taking part in this study
is up to you. You can stop taking part in it
at any time. It will not get in the way of
your care at this clinic.
SOURCE: Doak et al. (1996). Reprinted with permission of the Oncology Nursing Society.

HEALTH SYSTEMS 217
CD-ROMs, and interactive multimedia programs. Findings from these stud-

ies are equivocal. Some show positive outcomes such as increased knowl-
edge or self-care ability, while others show no effect. Two of these studies
found no interaction between the technology-based intervention and the
literacy level of the individuals in the studies (Kim et al., 2001; Wydra,
2001). Simply transforming text versions of disease-specific education to
more visually oriented media (for example, CD-ROM), while associated
with improvements in satisfaction, does not appear to increase knowledge
among patients with limited health literacy (Kim et al., 2001).
Although there is not yet clear evidence about the effectiveness of these
types of technology-based communication techniques for improving health
literacy or mitigating the effects of limited health literacy, such techniques
are supported by research in the fields of commercial and social marketing,
health education, and health communication. Speaking of Health (IOM,
2002c) provides an overview of this evidence base. In addition, evaluation
of interventions to improve the informed consent process provide support
for technology-based communication techniques such as computerized de-
cision aids (Rostom et al., 2002), videotape plus physician communication
(Agre et al., 1997), telephone-based nursing interventions (Aaronson et al.,
1996), and audiovisual documentation of oral consent (video + audiotape +
photography) (Benitez et al., 2002).
The Foundation for Informed Medical Decision Making has produced
education videos intended to aid in patient decision-making as part of
shared decision-making programs in clinics, managed care organizations,
and other settings (Kasper et al., 1992). Based on studies indicating which
patient preferences are most likely to affect treatment choices, these prod-
ucts incorporate testimonials about patient experiences and describe the
consequences of different choices. A systematic review of this approach
indicated that such decision aids improve knowledge, reduce decisional
conflict, and stimulate patients to be more active in decision-making with-
out increasing anxiety, while having variable effects on decisions and out-
comes of decisions (O’Connor et al., 1999). Because health literacy is im-
portant to the shared decision-making process, this type of approach is
important to consider but, unfortunately, has not yet been evaluated with
patients with limited health literacy or limited literacy.
One widely used type of technology-based communication technique is
telephone-delivered interventions (TDIs) in which health-related counseling
and reminders are delivered using the telephone. Speaking of Health (IOM,
2002c) reports that the efficacy of such interventions is strongly supported
by the evidence base but that they are underused by diverse populations.
TDIs can vary by the type of service provider, the extent to which the call is
scripted and varies based on characteristics and responses of the individual,
and the extent to which subsequent calls take into account information

218 HEALTH LITERACY
BOX 6-4
Examples of Ongoing Approaches Using Technology-Based
Communication Techniques
• The Florida/Caribbean AIDS Education and Training Center, funded by HRSA,

is developing a CD-ROM and web site that can be accessed at a computer in
the provider’s office to present patient information to women who are neither
literate nor fluent in English. The draft format includes pictures with simulta-
neous narration in Creole or Spanish, and includes presentations for each com-
monly used antiretroviral medication that demonstrate how to take the medica-
tions as well as how to administer them to a child.
• The HRSA HIV/AIDS Bureau provides technical assistance and funding to the
Northwest AIDS Education & Training Center’s Minority AIDS Initiative called
Building Effective AIDS Response. This program developed a video centered
on increasing health literacy about HIV-infection in Native American communi-
ties in Washington, Oregon, Idaho, and Montana, and addressing the fear and
shame barriers to accessing health care.
• The Improving Diabetes Efforts across Language and Literacy project, devel-
oped at San Francisco General Hospital, intends to implement and evaluate
disease management programs tailored to the language and literacy levels of
patients with diabetes. The project will test the feasibility and acceptability of
health communication interventions in a public delivery system and compare
the effects of technologically oriented vs. interpersonally oriented chronic dis-
ease support. Diabetes patients will be randomized to receive (1) weekly phone
calls via an automated telephone diabetes management system that was de-
veloped with the assistance of patients with limited literacy, (2) monthly group
medical visits, or (3) usual care.
• CDC’s Health Communication Division has a cooperative agreement with the
University of Southern California’s Norman Lear Center to provide information
to TV shows, networks, writers, and producers. The Center develops tip sheets
on priority topics for CDC, arranges biannual briefings for the Hollywood Writ-
er’s Guild, and responds to requests from Hollywood producers for accurate
and timely information. Television programming can provide accurate, timely
information about disease, injury, and disability in their storylines for millions of
people in a format available and understood by everybody.
from other encounters with the individual (IOM, 2002c). In addition, TDIs
can be initiated by the individual through calls to helplines or services, or by
the health system, through outbound calls (IOM, 2002c). The effect of
these variable characteristics is yet to be evaluated among individuals with
low literacy and low health literacy.
Testimony to the committee has revealed a wide array of activities in
the category of technology-based communication techniques that are cur-
rently being used. Some of these are summarized in Box 6-4.

HEALTH SYSTEMS 219
Personal Communication and Education

Approaches in the category of personal communication and education
include efforts such as classes or health education sessions for patients or
other individuals, communication techniques used by health-care provid-
ers, and patient navigator programs. Although a review of the field of
health education programs is beyond the scope of this report, several stud-
ies in Table 6-3 evaluated the effectiveness of education programs or one-
on-one communication for individuals with low literacy skills. The study by
Paasche-Orlow and colleagues (2003) found that among a groups of adults
hospitalized for asthma exacerbation, all of the patients benefited from the
one-on-one instruction regarding medications and inhaler technique, and
that low health literacy as determined by the Short Test of Functional
Health Literacy in Adults (S-TOFHLA) was not related to the need for
additional instruction before understanding was achieved (see Table 6-3).
In contrast, a study of patients with diabetes by Rothman and colleagues
(2003) found that among the control group receiving no intervention, those
with higher health literacy as measured by the REALM were more likely to
achieve glucose control after 6 months than patients with low literacy, and
among the intervention group, there was no difference in glucose control
improvement between those with higher and lower health literacy (see
Table 6-3). These findings suggest that the intervention was successful at
mitigating the adverse effects of limited health literacy. The evaluation by
Schillinger and others (2003b) of physician’s use of an interactive commu-
nication strategy in which the physician assessed patient recall and compre-
hension is another promising approach for individuals with limited health
literacy. They found that the use of this strategy was associated with better
glycemic control, although higher health literacy as measured by the S-
TOFHLA was also associated with good glycemic control.
Programs using community health workers and patient navigators use
one-on-one interaction to assist patients in navigating the health-care sys-
tem. Such programs show promise for helping to mitigate the effects of
limited health literacy since health system navigation has been noted as a
particular problem for individuals with limited health literacy. Community
health workers are known by various names (including lay health workers,
outreach workers, and promotoras) and are lay members of the commu-
nity who work in association with the local health-care system to provide
health education, interpret health information, and assist in obtaining ac-
cess to services. HRSA’s Bureau of Primary Health Care plays a large role
in training and providing support to community health workers in a num-
ber of settings, including farm worker promotoras at its Migrant Health
Centers.
Patient navigator programs are often run by hospitals or other health-

220 HEALTH LITERACY
care systems, and many historically have been designed for patients with
cancer. One of the first patient navigator programs was initiated by Harold
P. Freeman in 1990 at what was then Harlem Hospital Center in New York
City. The impetus for the program came from findings by the American
Cancer Society that poor people face specific barriers when attempting to
seek diagnosis and treatment of cancer and that these barriers result in
failure to seek care, or diagnosis at a later—and less treatable—stage of
disease. This program seeks to alleviate financial barriers, communication
and information barriers, medical system barriers (such as missed appoint-
ments and lost results), and fear and emotional barriers by providing a
navigator to patients with suspicious results from initial screening tests. The
navigator acts as the patient’s advocate in the interval between the screen-
ing and further diagnosis or treatment, assisting with such practical issues
as paperwork for financial support, childcare, or transportation problems.
The navigator also may translate medical jargon into understandable lan-
guage, provide education about the disease and its treatment, assist the
patient in communicating with and asking questions of his or her doctor,
and be available to listen to fears and concerns (Health Care Association of
New York, 2002). Follow-up from the first two years of the program
showed that 87.5 percent of patients with navigators completed recom-
mended breast biopsies, while the rate in patients without a navigator was
56.6 percent. Patients with navigators also completed the biopsy in signifi-
cantly less time than those without navigators (Freeman et al., 1995). The
Patient Navigator Program continues at the newly established Ralph Lauren
Center for Cancer Care and Prevention in Harlem, and similar programs
have since been established in other settings such as Solano County, Cali-
fornia, where a Patient Navigator Program was founded in 1999 by the
Solano Coalition for Better Health–Community Cancer Task Force
(CancerActionNOW.org, 2003) and at the Washington Cancer Institute in
Washington, DC.
Combined Approaches
Some approaches to health literacy have incorporated a number of the
different types of approaches discussed above into one intervention. A
study by Davis and colleagues (1998a) at a public hospital in Louisiana
(shown in Table 6-3 above) sought to increase mammography usage in
women attending ambulatory and eye clinics. One of the interventions
provided a personal recommendation from one of the investigators, an
easy-to-read brochure, and a 12-minute education program using a video
based on focus groups. Results of this randomized controlled trial showed
that this combined approach intervention was the only significant predictor
of increased mammography usage at 6 months after controlling for literacy,

HEALTH SYSTEMS 221
age, race, and baseline knowledge; patients who received only a recommen-
dation or only a brochure did not show increased mammography usage.
Similarly, some promising interventions that have sought to improve under-
standing for informed consent involve the combined use of simplified writ-
ten and verbal presentation to help patients better understand and concen-
trate on the information (Chan et al., 2002; Langdon et al., 2002; Muss et
al., 1979; Sorrell, 1991; Tindall et al., 1994; Young et al., 1990). Research
about the effectiveness of combining tailored print communications with
TDIs remains equivocal, with some studies supporting increased effective-
ness while others showed no effect. This research is reviewed in Speaking of
Health (IOM, 2002c). Molina Healthcare, a managed care organization
that focuses on low-income and Medicaid populations, conducted an evalu-
ation of a low-literacy program of this combined type. Families with a child
younger than six years of age were randomly assigned to either the control
group (n = 13,737 and 5,614 at 2 years) or an intervention group (n =
28,366 and 12,079 at 2 years) that received a self-help book in the mail,
plus follow-up reminders. The self-help book was appropriate for low-
literacy populations and was intended to supplement information provided
by advice nurses that are available by phone to all plan members. Results
after two years showed decreases among the intervention group in parents
taking their child to the emergency department for fever, rash, and diar-
rhea/vomiting and increases in parental self-efficacy for the same symp-
toms. The intervention group also demonstrated a decrease in calls to the
advice nurse, and were more likely to still be members of the plan after two
years than those in the control group (Ryan, 2003).
Box 6-5 describes a promising combined approach to health literacy
that uses written materials, patient educators, provider communication tech-
niques, and follow-up telephone calls.
Tailored Materials
As Chapter 4 emphasizes, culture gives significance to health informa-
tion and messages and thus approaches to health literacy should consider
the background and experiences of people. Patient viewpoints can provide
important insights about what, how, when, where, and in what manner
information can best be presented. Research on the informed consent pro-
cess that has looked at the experience from the perspective of the patient
has found that this can aid in untangling the complex dynamics associated
with the process (Albrecht et al., 2003; Cox, 2002; Ruckdeschel et al.,
1996). As Ratzan (2001) points out, the challenge in designing effective and
understandable health communications is to determine the optimal context,
channels, and content which reflect the realities of people’s everyday lives,
situations, and communication practices. In this way, messages are

222 HEALTH LITERACY
BOX 6-5
Chronic Disease Management Program
Researchers and practitioners at the University of North Carolina have developed

several chronic disease management programs that are designed to identify and
overcome literacy-related barriers to care. The programs, which include interven-
tions for diabetes, heart failure, chronic pain, and anticoagulation, are led by mid-
level providers, mainly clinical pharmacist practitioners, who use evidence-based
algorithms, a computerized patient registry, and literacy-independent teaching
techniques to facilitate effective self-care and assure receipt of effective services
and medications. The teaching techniques are used by clinical pharmacists and
trained health educators in a one-on-one interaction with the patient during clinic
visits, and feature:
• A teach-back method in which the patient teaches the content back to the ed-
ucator
• Practical skills rather than complex physiology
• Written educational materials designed for low-literacy users that the educator
reviews with the patient
• Follow-up telephone calls and quick visits by the educator when the patient
returns to the clinic that serve to reinforce the education
• A collaborative learning environment based on sensitivity to the role of literacy
in communication with patients
In each area, the program organizers have systematically measured literacy as

well as relevant health outcomes. For diabetes and anticoagulation, completed
studies have found that these programs can mitigate the adverse effects of low
literacy. Studies in heart failure and chronic pain are ongoing. Their success in
improving outcomes has led to stable funding for these programs from the hospi-
tal’s quality improvement department.
grounded within the sociopolitical and environmental structures of the

community and can better reflect the everyday lives of people. Furthermore,
health information that is developed from an interdisciplinary approach is
more likely to be effective, adopted, and successfully diffused within indi-
vidual communities (Allen, 2001; Manderson, 1999; Watters, 2003). Project
Toolbox is one example of an approach that used the viewpoints and
experiences of the intended population to design the program; it is de-
scribed in Box 6-6.
Similarly, characteristics of the individual patient or the target popula-
tion can be used to tailor existing materials to fit specific situations. This is
frequently done using computer-based algorithms that take various patient
characteristics into account. These characteristics might include language,
age, gender, ethnicity, reading ability, health literacy level, and the specific

HEALTH SYSTEMS 223
BOX 6-6
Description of Project Toolbox
Project Toolbox, funded by the State of Florida in 1999, represented a communica-

tion initiative of the H. Lee Moffitt Cancer Center & Research Institute. This project
aimed to develop culturally, linguistically, and literacy relevant educational tools for
community health-care providers and lay health educators for reaching medically
underserved African-American and Hispanic migrant and seasonal farm workers
with breast, cervical, and prostate cancer early detection and screening informa-
tion. Four English and Spanish language toolboxes were created using social
marketing and community-participatory research processes (Meade et al., 2002;
Meade et al., 2003). Each toolbox contained a videotape, flipchart, educational
brochures, and facilitator guide. Materials were written at a grade 3–4 reading
level. Concepts were communicated using visuals, testimonials, and pictures that
fit the everyday realities of the intended audiences.
questions, needs, and goals of the patient at that time. Research on tailored
print communications has typically shown that they can improve health
outcomes (for review, see Revere and Dunbar, 2001) but research also
suggests that they are less effective at influencing individuals who are not
thinking about making a behavior change (IOM, 2002c). Hayes (1998)
found that patients who received easily readable tailored discharge instruc-
tions subsequently performed better on a test of medication knowledge
than patients given the standard preprinted instructions (see Table 6-3).
Some current approaches that have come to the attention of the committee
also use this strategy. For example, the Veterans Administration designed
and distributes a “Flu Toolkit” that can be tailored to the educational and
cultural needs of specific locales. Another example is currently being inves-
tigated by researchers at the University of California–San Francisco. They
have developed a simple new communication tool that allows clinicians to
print for their patients an individualized, visual medicine schedule (VMS).
The VMS is a computer-generated, single page of paper that contains the
names and digital images of the prescribed doses of medication, with sym-
bols signifying the daily dosing schedule. The VMS displays the doses on a
weekly calendar to accommodate participants with medication doses that
differ from day to day. It can be updated and printed by the provider using
a color printer and can include instructions in Spanish and Chinese in
addition to English.
However, such approaches may not meet the needs of those with lim-
ited health literacy. Investigators from the Department of Obstetrics and
Gynecology at the University of California–San Francisco have developed
and evaluated a computerized, prenatal-testing, decision-assisting tool (“PT

224 HEALTH LITERACY
Tool”), which is designed to inform pregnant women (and their partners)

about prenatal testing options, and to assist them in making informed
choices regarding prenatal testing for chromosomal disorders. The PT Tool
provides background information about chromosomal abnormalities and
other birth defects, highlighting the personal nature of prenatal testing
decisions and the important role of individual preferences and values. The
information is tailored for the individual patient, providing individualized
risk estimates and allowing women to assess their own preferences and
select testing options and strategies about which they would like more
information. In a recently completed randomized controlled trial, it was
found that women who viewed PT Tool had significantly greater knowl-
edge, more satisfaction, and less decisional conflict than women who viewed
a computerized version of the educational pamphlets distributed to preg-
nant women by the State of California. Furthermore, women viewing PT
Tool differed in their testing inclination toward and utilization of prenatal
testing. That these effects were particularly strong in college-educated
women, raises questions about whether the tool would be effective for
individuals with limited health literacy. The investigators are now develop-
ing a new, lower-literacy version of PT Tool that will be more engaging and
accessible through the use of narrated animations and visual displays.
Partnerships
The increasing complexity of health systems—including new defini-
tions of health, evolution of new media and the discovery of innovative
biologic and genomic interventions, as well as the needs of diverse audi-
ences—demands broad, interdisciplinary, multisectoral approaches. An
IOM report, Bridging Disciplines in the Brain: Behavioral and Clinical
Sciences, observes that “Solutions to existing and future health problems
will likely require drawing on a variety of disciplines and approaches in
which interdisciplinary efforts characterize not only the cutting edge of
research but also the utilization of knowledge” (IOM, 2000a: 1).
To advance health literacy, it will be necessary to develop coordinated
activities with local programs and institutions that improve quality and
access to services, strengthen systems, and formulate effective policies.
This includes fostering broad, interdisciplinary approaches to health lit-
eracy and supporting the design and management processes necessary to
make them successful. Additionally, this requires involvement beyond the
traditional health-care system with universities, training institutions, pri-
vate- and public-sector media, and governmental social service depart-
ments.
A number of promising approaches brought to the committee’s atten-
tion have featured interdisciplinary partnerships. Among the longest run-

HEALTH SYSTEMS 225
ning and most well-known of these is the National Literacy and Health
Program in Canada which currently involves a partnership among 27 na-
tional organizations in Canada and is coordinated by the Canadian Public
Health Association. In existence for more than a decade, its objectives are
to (1) raise awareness among health professionals about the links between
literacy and health; (2) build commitment among participating national
health associations to promote literacy and health; and (3) establish links
between national health associations and the federal government, literacy
organizations, and provincial health associations in order to coordinate
action on literacy and health. The program has undertaken a number of
major projects such as producing a multimedia training resource for health
professionals, providing a literacy and health curriculum for youth, and
producing guidelines for prescription medication manufacturers. Although
the National Literacy and Health Program has not as yet been evaluated
formally (such an evaluation is currently under way), it appears to have had
a major impact on both the health professional and literacy community in
Canada.
In the United States, federal-level collaborative efforts have revolved
around Healthy People 2010 (HHS, 2000). Healthy People 2010, as previ-
ously discussed, includes an objective on health literacy which is “to im-
prove the health literacy of persons with marginal or inadequate literacy
skills.” The Office of the Secretary, ODPHP is the lead agency for this
objective, and has been working to identify and coordinate health literacy
activities across HHS, to convene HHS agencies to work collaboratively on
health literacy, and to identify external partners. In 2000, ODPHP estab-
lished a partnership with the National Center for Education Statistics, U.S.
Department of Education, to develop health literacy measures that are
included in the 2003 National Assessment of Adult Literacy. This assess-
ment will provide the first national measures of health literacy. ODPHP has
also collaborated with outside organizations on health literacy including
the AMA and the Academy of General Dentistry.
Some state- and local-level partnerships also currently exist. For ex-
ample, the Santa Clara (California) Medical Center, Santa Clara County
Library, and Plane Tree Health Library have partnered since 2001 to oper-
ate a center for health literacy on the Medical Center campus. The commu-
nity learning center provides information on a variety of medical topics and
conditions in English, Spanish, and Vietnamese in a variety of formats
(print, audio, and video) with a focus on easy-to-read materials. The Medi-
cal Center provides space readily accessible to patients, the Plane Tree
Library provides supervision and expertise in resource development, and
the Santa Clara Library recruits adult literacy students to visit the Center
and provide literacy support to patrons referred by health-care providers.
Since May 2001, more than 2,000 clients have been served.

226 HEALTH LITERACY
Summary of Approaches
It can be seen that, as in the survey, most of the examples and studies
cited above fall into the category of “simplifying materials,” which includes
issues of multiple languages and translation, and can be used for enhanced
provider–patient communication as well as in other settings. Several of
them include the dimension of testing materials with the intended users for
understanding and subsequently making appropriate modifications, which
the committee has noted is very important. Some work is now in progress
to develop nonprint approaches, such as visual aids, computer instruction,
and entertainment programs. Many of the federal and some state efforts are
in the training area, most notably many of the programs in the multiple
bureaus of the HRSA. The emerging partnerships in both the public and
private sectors will be critical if sustained and systematic progress is to be
made.
When respondents to the survey discussed above were asked an open-
ended question about lessons learned from their health literacy activities,
three fairly consistent themes about lessons learned emerged:
1. Organizational support and policies are lacking

2. Quality standards are needed
3. A variety of health literacy modalities are needed to be effective
Some comments from survey responders that correspond to each of these

themes appear in Box 6-7 to illustrate current sentiment in the field.
This glimpse of ongoing activities from the literature, from the survey,
and from testimony and Committee knowledge indicates that concerned
organizations and individuals have recognized the complexity of the health
literacy problem and have begun to simplify and pilot test materials, and to
acknowledge the need to test a wide variety of health literacy approaches.
This is a substantial improvement from the 1980s and early 1990s. How-
ever, it also highlights the lack of national- and organizational-level policy.
Health literacy activities seemed to be based on the interest and determina-
tion of a few people within organizations who frequently are not policy
makers. Increased awareness and activities related to health literacy appear
to spread anecdotally rather than as a result of policy. This type of ap-
proach to the problem of limited health literacy is not sufficient to ensure
continued interest and improvement in health literacy interventions. The
next decade must see a significant increase in the number of programs and
approaches that are developed and evaluated, as well as more systematic
approaches and partnerships within and across both the public and private
sectors.

HEALTH SYSTEMS 227
BOX 6-7
Comments from Respondents to Survey
1. Organizational support and policies are lacking; health-literacy approaches are

typically led by a few individuals within organizations.
• “The most pressing thing in the field right now is that many individuals are
trying to make health literacy an issue in their organizations but they lack
organizational/management support.”
• “Too many roadblocks exist; policy shifts are needed locally and nationally.”
• “Executive leadership/attention is needed.”
• “Visible department level support is needed for health literacy.”
• “We WANT to serve the American public well . . . but there are certainly a lot
of extra bureaucratic hurdles that make this a lot harder than it should be.”
• “As long as consumer communication is marginalized within organizations
(an afterthought to the main agenda) health literacy will be ignored.”
• “Healthcare organizations will not invest in health-literacy interventions until
someone shows them the business case for doing so.”
• “Having a pharmaceutical company (Pfizer) take ownership is not sufficient
and privatized the agenda.”
2. Quality standards are needed.
• “There need to be quality standards for training in this field.”
• “Health literacy needs to be part of staff orientation—at all levels.”
• “Quality standards for designing materials and learning approaches need to
be established.”
• “Quality standards are needed to provide the support necessary to make a
difference in health-literacy initiatives.”
• “Most health professionals don’t know about the issues of health literacy
and plain language and can’t define either term.”
• “We find that staff develop material that tells too much ‘why’ when patients
need the ‘what’.”
3. A variety of health-literacy modalities are needed to be effective.
• “In order to be effective, health messages need to audience-specific and
use various modalities.”
• “Developing materials for consumers is a science. Unfortunately, there is
not one solution that fits everyone.”
• “Information is only useful if it is appropriate for the intended audience.”
• “Sending a message is not enough, you need to be sure that your message
has been conveyed properly.”
• “To be effective health communication needs to involve the intended audi-
ence in the development of information/education products.”
• “Language and cultural competence and varied strategies and methods ap-
propriate to the identified audience are key to creating useful materials.”

228 HEALTH LITERACY
Finding 6-1 Demands for reading, writing, and numeracy skills are intensified
because of health-care systems’ complexities, advancements in scientific discov-
eries, and new technologies. These demands exceed the health-literacy skills of
most adults in the United States.
Finding 6-2 Health literacy is fundamental to quality care, and relates to three of
the six aims of quality improvement described in the IOM Crossing the Quality
Chasm report: safety, patient-centered care, and equitable treatment. Self-man-
agement and health literacy have been identified by IOM as cross-cutting priorities
for health-care quality and disease prevention.
Finding 6-3 The readability levels of informed consent documents (for research
and clinical practice) exceed the documented average reading levels of the major-
ity of adults in the United States. This has important ethical and legal implications
that have not been fully explored.
Recommendation 6-1 Health-care systems, including private systems, Medi-

care, Medicaid, the Department of Defense, and the Veterans Administration
should develop and support demonstration programs to establish the most effec-
tive approaches to reducing the negative effects of limited health literacy. To ac-
complish this, these organizations should:
• Engage consumers in the development of health communications and in-
fuse insights gained from them into health messages.
• Explore creative approaches to communicate health information using print-
ed and electronic materials and media in appropriate and clear language. Messag-
es must be appropriately translated and interpreted for diverse audiences.
• Establish methods for creating health information content in appropriate and
clear language using relevant translations of health information.
• Include cultural and linguistic competency as an essential measure of qual-
ity of care.
Recommendation 6-2 HHS should fund research to define the needed health-
literacy tasks and skills for each of the priority areas for improvement in health-care
quality. Funding priorities should include participatory research that engages the
intended populations.
Recommendation 6-3 Health literacy assessment should be a part of health-

care information systems and quality data collection. Public and private accredita-
tion bodies, including Medicare, NCQA, and JCAHO, should clearly incorporate
health literacy into their accreditation standards.
Recommendation 6-4 HHS should take the lead in developing uniform stan-
dards for addressing health literacy in research, service, and training applications.
This includes addressing the appropriateness of research design and methods
and the match among the readability of instruments, the literacy level, and the
cultural and linguistic needs of study participants. In order to achieve meaningful
research outcomes in all fields:

HEALTH SYSTEMS 229
• Investigators should involve patients (or subjects) in the research process

to ensure that methods and instrumentation are valid and reliable and in a lan-
guage easily understood.
• NIH should collaborate with appropriate federal agencies and institutional
review boards to formulate the policies and criteria to ensure that appropriate con-
sideration of literacy is an integral part of the approval of research involving human
subjects.
• NIH should take literacy levels into account when considering informed con-
sent issues in human subjects research. IRBs should meet existing standards re-
lated to the readability of informed consent documents.
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A Vision for a
Health-Literate America
My best advice to others with poor reading skills is to not presume but to ask
questions. Poor readers need to take responsibility also. We need to learn
how to ask questions better. I would recommend more training for us. Re-
member, we [adult learners] want to be part of the solution.
My best advice to health providers is to think of us as partners. Treat us like

partners. Tell us that you need our help too. You might think about setting up
training sessions to help staff know how to ask questions that get the best
answers. Make sure compassion is part of the training and include us in the
training. We can teach along with you. When talking with us, use pictures
(those drawn by you are just as good as the fancy ones—even stick figures).
Use plain language not medicalese.
Personal story graciously provided by Toni Cordell, Adult Learner and Lit-
eracy Advocate, as told to C.D. Meade, September 2003.
T
he evidence and judgment presented in this report indicate how
important improving heath literacy is to improving the health of
individuals and populations. This is why the Institute of Medicine
identified improving health literacy as one of two cross-cutting issues need-
ing attention in its recent Priority Areas for National Action in Quality
Improvement (IOM, 2003), and why the Surgeon General recently stated
that “health literacy can save lives, save money, and improve the health and
240

VISION FOR A HEALTH-LITERATE AMERICA 241
well-being of millions of Americans . . . health literacy is the currency of

success for everything I am doing as Surgeon General” (Carmona, 2003).
As the report also indicates, much more needs to be known about the
causal pathways between education and health and the more specific role of
literacy, as well as the discrete contribution of health literacy. As a result,
we will then be in a position to understand which interventions and ap-
proaches are the most appropriate and effective. This Committee believes
that a health-literate America is an achievable goal. We envisage a society in
which people have the skills that they need to obtain, interpret, and use
health information effectively, and within which a wide variety of health
systems and institutions take responsibility for providing clear communica-
tion and adequate support to facilitate health-promoting actions. Specifi-
cally, we believe a health-literate America would be a society in which:
• everyone has the opportunity to improve their health literacy.

• everyone has the opportunity to use reliable, understandable infor-
mation that could make a difference in their overall well-being, including
everyday behaviors such as how they eat, whether they exercise, and
whether they get checkups.
• health and science content would be basic parts of K-12 curricula,
• people are able to accurately assess the credibility of health infor-
mation presented by health advocate, commercial, and new media sources.
• there is monitoring and accountability for health literacy policies
and practices.
• public health alerts, vital to the health of the nation, are presented
in everyday terms so that people can take needed action.
• the cultural contexts of diverse peoples, including those from vari-
ous cultural groups and non-English-speaking peoples, are integrated into
all health information.
• health practitioners communicate clearly during all interactions
with their patients, using everyday vocabulary.
• there is ample time for discussions between patients and health-
care providers.
• patients feel free and comfortable to ask questions as part of the
healing relationship.
• rights and responsibilities in relation to health and health care are
presented or written in clear, everyday terms so that people can take needed
action.
• informed consent documents used in health care are developed so
that all people can give or withhold consent based on information they need
and understand.

242 HEALTH LITERACY
While achieving this vision is a profound challenge, we believe that

significant progress can and must be made over the coming years so that the
potential of optimal health can benefit all individuals and populations in
our society.
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Carmona RH. 2003. Health Literacy in America: The Role of Health Care Professionals.
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speeches/ama061403.htm [accessed: August 2003].
IOM (Institute of Medicine). 2003. Priority Areas for National Action: Transforming Health-
care Quality. Adams K, Corrigan JM, Editors. Washington, DC: The National Acad-
emies Press.

Data Sources and Methods
I
n order to respond to the study charge, several steps were undertaken to
define the scope of the problem of limited health literacy, identify ob-
stacles to creating a health-literate public, assess the approaches that
have been attempted, and identify goals for health literacy efforts. Sources
of data and information included the expertise of the committee members,
literature reviews and Internet searches of principal concepts, informal in-
terviews, commissioned works, hosting of several public workshops, and
other invited presentations.
STUDY COMMITTEE
An 11-member study committee was convened to assess available data
and respond to the study charge. The committee included members with
expertise in public health, primary medical care, health communication,
sociology, anthropology, adult literacy education, and K-12 education. The
committee convened for six 2-day meetings on October 21–22, 2002; De-
cember 10–11, 2002; February 13–14, 2003; April 29–30, 2003; June 16–
17, 2003; and September 11–12, 2003. Biographies of individual commit-
tee members appear in Appendix D.
LITERATURE REVIEW
The committee conducted extensive literature reviews and Internet
searches regarding health literacy and related topics. The literature reviewed
243

244 HEALTH LITERACY
in this report represents diverse fields and academic disciplines. In particu-

lar, Institute of Medicine (IOM) staff used in-house databases, including
Academic Premier Search, Medline, ERIC,1 PsychInfo, Sociological Ab-
stracts, and CINAHL2 to identify relevant peer-reviewed literature. Key-
word searches include the following: “health literacy,” “literacy and
health,” and “reading and health.” Additional studies for consideration
were identified through testimony to the committee by experts in the field.
PUBLIC WORKSHOPS
The study committee hosted three 1-day public workshops in order to
obtain input from various stakeholders, consumers, and researchers. These
workshops were held in conjunction with three of the six committee meet-
ings mentioned above.
The first public workshop of the committee was held on December 10–
11, 2002 in Washington, DC. This workshop focused on health literacy-
related activities in federal government agencies, academia, and other rel-
evant organizations. Michael Pignone, M.D., M.P.H., Assistant Professor
of Medicine at the University of North Carolina, Chapel Hill, School of
Medicine, presented information about an ongoing research project spon-
sored by the Agency for Health Care Research and Quality intended to
review the evidence base of health literacy research. Arlene S. Bierman,
M.D., M.S., from the Center of Outcomes and Effectiveness Research,
Agency for Healthcare Research and Quality, spoke about health dispari-
ties and health literacy. Lawrence J. Fine, M.D., Dr. P.H., of the Office of
Behavioral and Social Science Research at the National Institutes of Health,
discussed how health literacy relates to other areas in health such as health
disparities, behavioral change, and socioeconomic determinants of health
such as education. Cynthia Baur, Ph.D., of the U.S. Department of Health
and Human Services, spoke about federal involvement in health literacy
efforts and how to leverage existing work that is relevant to the field.
Anthony Tirone, J.D., from the Joint Commission on Accreditation of
Healthcare Organizations (JCAHO), discussed some of the work of JCAHO
that has implications for how health systems respond to health literacy.
Marisa Scala, M.G.S., from the Center for Medicare Education of the
American Association of Homes and Services for the Aging, talked about
the specific needs of the Medicare population as they relate to health lit-
eracy. Karen Lechter, J.D., Ph.D., from the Center for Drug Evaluation and
Research of the U.S. Food and Drug Administration (FDA) provided an
1Educational Resources Information Center.


APPENDIX A 245
overview of the activities of the FDA and their relevance to health literacy.
Lauren Schwartz, M.P.H., from the New York City Poison Control Center
shared background about and lessons from a program educating adult
learners about medications. Linda Morse, R.N., M.A., from the New Jersey
Office of Academic and Professional Standards discussed current activity in
the educational sector to improve health literacy, including efforts specific
to New Jersey, such as the New Jersey Core Curriculum Content Standards
for Comprehensive Health and Physical Education, which are currently
being implemented. Judy A. Shea, Ph.D., from the University of Pennsylva-
nia School of Medicine, shared findings about a recent research project
looking at the interplay between health literacy and patient satisfaction
with different modes of health-related communication. Finally, Tina Tucker,
M.A., M.Ed., RTC, from the National Program in Literacy, American Foun-
dation for the Blind, discussed the health needs and desires of individuals
who are visually impaired and low literate. The agenda for this workshop is
shown in Box A-1.
The third meeting of the committee was held on February 13–14, 2003,
at the Arnold and Mabel Beckman Center of the National Academies in
Irvine, California, and a public workshop was held in conjunction with this
meeting. On the afternoon of February 13, the committee heard from rep-
resentatives of consumer and advocacy groups, as well as several experts in
the areas of literacy, communication, and chronic diseases. Dean Schillinger,
M.D., from the University of California–San Francisco spoke about the
relationships between care for patients with chronic diseases, health lit-
eracy, and quality of care, with a specific emphasis on the role of patient–
physician communication in determining quality of care. Tetine Sentell,
M.A., of the University of California–Berkeley presented new analyses of
data from the National Adult Literary Survey. Susan M. Shinagawa, from
the Asian and Pacific Islander National Cancer Survivors Network, and
Heng L. Foong, of the Pacific Asian Language Services for Health, high-
lighted the most critical health literacy issues facing Asian Americans and
Pacific Islanders today, with an emphasis on issues of health and doctor–
patient communication in populations with limited English that represent
native speakers of diverse languages. Rita Hargrave, M.D., of the Univer-
sity of California–Davis and Veterans Medical Center of Northern Califor-
nia, discussed mental health care, ethnicity, and health literacy, and the
influence of physician and patient communication styles and preferences.
Alvin Billie, of the Family Learning Center and the Gathering Place in New
Mexico, discussed the unique health literacy issues facing Native Ameri-
cans, and addressed the effect of large cultural differences on doctor–
patient communication, as well as approaches to the problems created by
these cultural differences. Francis Prado and Francisco Para, from Latino
Health Access based in Santa Ana, California, described health literacy

246 HEALTH LITERACY
BOX A-1
First Workshop Hosted by the Committee on Health Literacy
Date: December 10–11, 2003

Location: Keck Center of the National Academies
500 5th Street, NW
Washington, D.C.
December 10, 2003

1:00 p.m. Report from the AHRQ Evidence-Based Practice Center Report
on Health Literacy
Michael Pignone, M.D., M.P.H.
Assistant Professor of Medicine, University of North Carolina at
Chapel Hill School of Medicine
1:20 p.m. Health Literacy and Health Disparities: Assessing Health
Outcomes and Quality of Care
Arlene S. Bierman, M.D., M.S.
Senior Research Physician, Center of Outcomes and Effectiveness
Research, Agency for Healthcare Research and Quality
1:50 p.m. Education Pathways to Health: Health Literacy
Lawrence J. Fine, M.D., Dr.Ph., Medical Advisor
Office of Behavioral and Social Science Research, National
Institutes of Health
2: 00 p.m. The Federal Sector and Health Literacy
Cynthia Baur, Ph.D.
Health Communication and e-Health Advisor, U.S. Department of
Health and Human Services
2:30 p.m. Activities of the Joint Commission to Improve Health Literacy
Anthony Tirone, J.D.
Director of Federal Relations, Joint Commission on Accreditation of
Healthcare Organizations
3:00 p.m. Break
challenges in Latin American populations based on their experiences as

community health workers, emphasizing how the different experiences of
patients and doctors affect the meaning in their communication, resulting
in less effective health care. The agenda for this meeting is presented in Box
A-2.
At the fourth meeting of the committee, a public workshop was held
with representatives of health-care system organizations and consumer
groups, as well as experts on the research base on health literacy and on the
legal issues surrounding health literacy. This workshop took place on April

APPENDIX A 247
3:15 p.m. Linking Health Literacy and Medicare Education

Marisa Scala, M.G.S.
Executive Director, Center for Medicare Education, American
Association of Homes and Services for the Aging
3:45 p.m. Patient Information Activities at the FDA
Karen Lechter, J.D., Ph.D.
Social Science Analyst, Center for Drug Evaluation and Research,
U.S. Food and Drug Administration
4:15 p.m. General Discussion and Public Comment
5:00 p.m. Adjourn
December 11, 2003

8:30 a.m. Health Education Literacy Program: A Medicine Safety Program
for Adult Learners
Lauren Schwartz, M.P.H.
Community Health Educator, New York City Poison Control Center
9:15 a.m. Improving Health Literacy: An Educational Response to a
Public Health Problem
Linda Morse
Director, New Jersey Office of Academic and Professional Standards
10:00 a.m. Development of Patient Satisfaction Survey Materials for
Low-Literacy Consumers
Judy A. Shea
University of Pennsylvania School of Medicine
10:45 a.m. Health Management Solutions for Adults Who Are Visually
Impaired and Have Low Literacy Skills
Tina Tucker
American Foundation for the Blind
11:30 a.m. Discussion
12:30 a.m. Adjourn
29, 2003, at the Keck Center of the National Academies in Washington,

DC. Michael Pignone, Ph.D., of the University of North Carolina at Chapel
Hill presented updated information about an ongoing study on the health
literacy research database sponsored by the Agency for Healthcare Re-
search and Quality. Julie Hudman, Ph.D., from the Kaiser Commission on
Medicaid and the Uninsured of the Henry J. Kaiser Family Foundation
spoke about the health literacy issues confronting Medicaid and low-in-
come individuals. Joanne Schwartzberg, M.D., of the American Medical
Association (AMA), discussed the ongoing efforts of the AMA to educate

248 HEALTH LITERACY
BOX A-2
Second Workshop Hosted by the
Committee on Health Literacy
Date: February 13, 2003

Location: Arnold and Mabel Beckman Center of the National Academies,
Irvine, CA
3:00 p.m. Literacy and Chronic Disease Care: New Research Insights and
Reflections on Quality Standards
Dean Schillinger, M.D.
Associate Professor of Medicine, University of California–San
Francisco, San Francisco General Hospital Medical Center
3:45 p.m. Relationships Between Literacy, Race, Age, Education, and
Health in a National Sample: An Extension of NALS Analyses
Tetine Sentell, M.A.
Ph.D. Candidate, University of California, Berkeley
4:00 p.m. Health Literacy Concerns for Asian Americans & Pacific
Islanders: Challenges and Opportunities
Susan M. Shinagawa
Patient Advocate and Founder, Asian and Pacific Islander National
Cancer Survivors Network
Heng L. Foong
Patient Advocate and Program Director, Pacific Asian Language
Services for Health
4:15 p.m. The Interplay of Ethnicity and Health Literacy in Mental Health-
care
Rita Hargrave, M.D.
Assistant Professor of Psychiatry, Department of Psychiatry,
University of California, Davis, Veterans Medical Center of
Northern California System of Clinics
4:30 p.m. Health and Literacy—A Native American Point of View
Alvin Billie
Program Manager, The Gathering Place, Thoreau, NM
4:45 p.m. Health Care Barriers in the Latino Community of Orange County
Francis Prado, Francisco Para
Health Educators and Promotoras, Latino Health Access
5:00 p.m. Discussion
5:30 p.m. Adjourn
health professionals about health literacy. Frank M. McClellan, J.D., a

professor at the Temple University James E. Beasley School of Law, pro-
vided background on the legal precendents and legal and ethical implica-
tions of health literacy and informed consent. Joyce Dubow, M.U.P., of

APPENDIX A 249
AARP, spoke about health literacy issues related to Medicare beneficiaries.

L. Natalie Carroll, M.D., of the National Medical Association, presented
information on African Americans and health literacy, and described the
positions and efforts of the National Medical Association in the area. Fi-
nally, Eduardo Crespi, R.N., from Centro Latino de Salud in Missouri,
discussed health literacy needs of the Latin American population served by
Centro Latino, and described some of the programs available to address
those needs. The agenda for this workshop is presented in Box A-3.
BOX A-3
Third Workshop Hosted by the Committee on Health Literacy
Date: April 29, 2003

Location: Keck Center of the National Academies, Washington, DC
2:00 p.m. Understanding the Medicaid and Low-Income Population:

Implications for Health Literacy
Julie Hudman, Ph.D.
Associate Director, Kaiser Commission on Medicaid and the
Uninsured, Henry J. Kaiser Family Foundation
2:30 p.m. Low Health Literacy: Increasing Physician Awareness of an
Emerging Issue
Joanne Schwartzberg, M.D.
Director of Aging and Community Health, American Medical
Association
3:00 p.m. Legal Implications of Health Literacy
Frank M. McClellan, J.D.
I. Herman Stern Professor of Law, Temple University James E.
Beasley School of Law
3:30 p.m. Break
3:45 p.m. Health Literacy Among Medicare Beneficiaries
Joyce Dubow, M.U.P.
Senior Policy Advisor, Public Policy Institute, AARP
4:15 p.m. African Americans and Health Literacy
L. Natalie Carroll, M.D.
President, National Medical Association
4:45 p.m. Health Literacy and the Midwestern Latino Community
Eduardo Crespi, R.N.
Executive Director, Centro Latino de Salud, Columbia, MO
5:15 p.m. Discussion
5:45 p.m. Adjourn

250 HEALTH LITERACY
COMMISSIONED PAPERS AND BACKGROUND INFORMATION

The committee commissioned several papers and research projects in
order to fill gaps in the available evidence base. Three of the papers can be
found in Appendix B, and input from other consultants has been integrated
into the report. The committee commissioned work from Terry Davis of
Louisiana State University, Julie Gazmararian of Emory University, David
H. Howard of Emory University, Frank McClellan of Temple University
School of Law, Dean Schillinger of University of California–San Francisco,
and Barry D. Weiss of the University of Arizona College of Medicine. Davis
and Gazmararian collaborated to examine some promising approaches to
health literacy; background and methodology of their work is discussed
further below. Howard was commissioned to look at the economic implica-
tions of limited health literacy in a Medicare population. His paper is
included in Appendix B, and provides important information for the discus-
sion in Chapter 3 concerning the associations of limited health literacy.
McClellan spoke to the committee and provided information about legal
issues that are important to consider with health literacy. This information
provides the basis for the section on health law that appears in Chapter 6.
Schillinger examined chronic disease care for patients with limited health
literacy from a health systems perspective. His work on informed consent is
cited in Chapter 6, and can be found in Appendix B. Weiss provided a piece
considering the different stakeholders in the health literacy discussion; this
work can also be found in Appendix B.
This section presents the methodology used for two of the research
activities commissioned by the committee from outside consultants that are
not separately presented in a paper: (1) a review of approaches to health
literacy not found in the published literature, and (2) a compilation of the
federal funding for health literacy projects over the past 10 years.
Approaches to Improving Health Literacy: Lessons from the Field

The committee commissioned a project from Terry Davis, M.D., Loui-
siana State University Health Sciences Center, and Julie Gazmararian, Ph.D.,
Emory University, to look at approaches to improving health literacy that
are currently being used and may not be reflected in the peer-reviewed
literature. Findings from this project are discussed in Chapter 6. Drs. Davis
and Gazmararian, and IOM staff, identified key individuals or organiza-
tions that should be contacted to inquire about health literacy activities in
which they were involved. The selection process was not intended to result
in a complete survey of approaches to health literacy, but rather to identify
a sample of key organizations that could make a difference in the field of
health literacy. The types of organizations that were targeted included fed-

APPENDIX A 251
eral and state government agencies, pharmaceutical companies, national

organizations, foundations, and local service providers. IOM staff identi-
fied a contact person to respond from each organization. Individuals iden-
tified for possible participation in the survey were those who were aware of
health literacy. We also decided to elicit information on health literacy
activities from the National Institute for Literacy (NIFL)-health listserv (see
www.nifl.gov for more information).
Terry Davis and Julie Gazmararian developed a 5-minute, 15-question,
web-based survey to send to selected individuals. This instrument was de-
veloped on the basis of a previous survey by the Council of State Govern-
ments to assess health literacy activities at the state level (Matthews and
Sewell, 2002). Information collected included: whether health literacy is
considered in program development and service activities; the degree to
which organizations follow health literacy principles in their programs;
target audience(s) for activities; whether organizations pilot test materials
for comprehension or cultural competence; evaluation of materials; which
activities people associate with health literacy and lessons learned.
The Internet service www.zoomerang.com was used to create the web-
based survey because it provides low-cost, web-based survey implementa-
tion tools. IOM staff sent an e-mail message with a web link to the original
list of 101 individuals identified, and to the NIFL-health listserv, which has
568 members. The survey was open for 10 days. No follow-up reminders
were sent to the designated individuals or the listserv.
Figure A-1 outlines the response to the survey. Of the 101 individuals e-
mailed, 7 e-mails were undeliverable, leaving 94 individuals directly con-
tacted. Including respondents from the listserv, we received completed sur-
veys from 95 individuals; 33 of these were from the initial list of individuals,
and 62 were from the listserv.
E-mail sent to targeted Survey posted on list serve

individuals (n=101) (n=568)
33 respondents 62 responded
7 e-mails
undeliverable
95 Responses
FIGURE A-1 Response to web-based survey.

252 HEALTH LITERACY
Respondents came from state and federal government agencies, asso-

ciations, foundations, health-care organizations, institutes of higher educa-
tion, community/advocacy groups, adult education programs, and literacy
businesses (see Table A-1).
TABLE A-1 Summary of Respondents and Nonrespondents to Survey

E-mailed Survey Respondents NIFL Listserv Respondents
Asian American Network for Cancer American Institutes for Research

Awareness, Research and Training American Society on Aging
American Academy of Family Physicians Ball Memorial Family Practice Residency
Foundation Blue Cross Blue Shield of Michigan
American Academy of Neurology Bronson Healthcare Group
American Medical Association Brown University, Center for
Agency for Toxic Substances and Disease Environmental Studies
Registry (CDC) Butler University–College of Pharmacy
California HealthCare Foundation Cambridge Health Alliance
California Literacy, Inc. Centers for Disease Control and
Center for Medicare Education Prevention
Centers for Disease Control and Center for Health Care Strategies
Prevention CHOICE Regional Health Network
Centro Latino de Salud Clear Language Group
Food and Drug Administration Dartmouth-Hitchcock Medical Center
Martinez VA Outpatient Clinic Eastern Massachusetts Literacy Council
Mettger Communications EasyRead Copywriting
National Cancer Institute Emory University School of Medicine/
National Program Office, Grady Hospital
Hablamos Juntos En Memphis, Hablamos Juntos
National Cancer Institute’s Cancer Environmental Toxicology Program,
Information Service of New York Maine Bureau of Health
National Institute on Deafness and Other Family Health Research
Communication Disorders (NIH) Georgia Department of Technical &
New York City Poison Control Center Adult Education
Pfizer, Inc. Hablamos Juntos
The Gathering Place Harris School of Nursing, Texas
U.S. Department of Health and Human Christian University
Services Health Literacy Center, University of
U.S. Food and Drug Administration, New England
Los Angeles District Health Literacy Consulting
University of North Texas Health Science Home Health VNA
Center Health Resources and Services
University of Virginia School of Medicine Administration
Inova Health System
Kootenai Medical Center Medical Library
Literacy Assistance Center
Literacy Volunteers of Santa Fe

APPENDIX A 253
TABLE A-1 Continued

E-mailed Survey Respondents NIFL Listserv Respondents
Massachusetts Department of Public

Health
Mayfield Adult Basic and Literacy
Education
Molina Healthcare, Inc.
National Alliance for the Mentally Ill
(NAMI)
National Institutes of Health
National Marrow Donor Program
National Cancer Institute—Office of
Education and Special Initiatives
Neighborhood Health Plan of Rhode
Island
National Institute of Neurological
Disorders and Stroke (NIH)
New York City Department of Health
and Mental Hygiene
Parma Adult Basic and Literacy
Education
Queens Library
Rancho Los Amigos National
Rehabilitation Center
Saint Eugene Medical Center
Santa Clara Valley Medical Center
Section of Patient Education Mayo Clinic
Rochester
Southwest Washington Medical Center
St. Joseph Regional Health Center
Temple University Health System
The Catholic University of America
School of Nursing
The Ohio State University
The Robert Wood Johnson Foundation
University of Texas
University of North Carolina School of
Medicine
University of Pennsylvania
University of South Carolina School of
Medicine
University of Tennessee Extension Service
University of Texas Health Science
Center
Virginia Adult Learning Resource Center
Vision Literacy
Wayne State University
NOTE: The same organization can be found in different categories because separate individu-
als may or may not have completed the survey.

254 HEALTH LITERACY
Federal Funding for Health Literacy over a 10-Year Period

Patrick Weld, M.S.W., M.P.A., L.G.S.W., of the National Cancer Insti-
tute (NCI), with the assistance of K. Vish Visnawath, Ph.D., also of NCI,
provided the committee with a table of federal funding of health literacy-
related projects over the past 10 years. The data were derived from a search
of the NIH CRISP database; searches for each fiscal year from 1993 to
2002 used the following operands: “health literacy,” “health and literacy,”
“health and readability,” and “literacy and readability.” The grants re-
trieved were examined for relevance to the field of health literacy, and
financial information was obtained.
Results were then downloaded into Portfolio Management Application
software developed by Department of Cancer Control and Population Sci-
ence of the National Institutes of Health for identification and deletion of
duplicate grants, and linkage to financial data. A total of 906 grants for the
10-year period were identified. Because of a technology change in 1995–
1996, 229 of the grants could not be linked to financial data. Thus, the
early years of the search results (1993–1996) contain missing financial
data. While Drs. Weld and Viswanath were able to identify all of the
missing grants, further work to access the financial data for those grants
was not successful.
The information for the remaining 667 grants available was down-
loaded into an Excel spreadsheet for further manipulation. The awarded
grants were identified, and unawarded grants were excluded, bringing the
final count of grants to 565. This information has been compiled into
yearly federal grant funding (new and continuing grants) over a 10-year
period, and is presented in Chapter 6.
REFERENCE

Commissioned Papers
CONTENTS
The Relationship Between Health Literacy and Medical Costs
David H. Howard 256
Improving Chronic Disease Care for Populations with Limited

Health Literacy
Dean Schillinger 267
Outside the Clinician–Patient Relationship: A Call to Action for

Health Literacy
Barry D. Weiss 285
255

256 HEALTH LITERACY
The Relationship Between

Health Literacy and Medical Costs
David H. Howard, Ph.D.
INTRODUCTION
Past research has shown that individuals with low levels of health
literacy are more likely to be hospitalized and have worse disease outcomes
(Baker et al., 1998, 2002; Schillinger et al., 2002). The major obstacle to
extending these results by examining the relationship between health lit-
eracy and spending is the lack of data containing measures of both. Some
insight about the impact of health literacy on costs can be gleaned from
studies that examine the impact of years of schooling on medical costs, but
health literacy is a fundamentally different concept from educational attain-
ment (Davis et al., 1994; Stedman and Kaestle, 1991). At least one study
has examined the association between general literacy and costs (Weiss et
al., 1994). It found no relationship, though the sample size was small (N =
402) and not representative of the overall U.S. population (over half the
study subjects qualified for Medicaid because of disability). Furthermore,
inpatient and outpatient costs were not analyzed separately and the analysis
did not control for confounding patient characteristics. Another paper by
the same author (Weiss) shows large differences in costs by grade reading
level in a Medicaid population (Weiss, 1999), but descriptions of the meth-
ods and data are not available. This study examines the relationship be-
tween health literacy and costs using a unique dataset combining cost infor-
mation from an administrative claims file and a health literacy measure
from a beneficiary survey. Multivariate techniques are used to adjust for
underlying differences in respondents’ characteristics.
Data Description
Health literacy data were collected as part of a survey of persons enroll-
ing in a Prudential Medicare health maintenance organization between
December of 1996 and August of 1997 in one of four locations: Cleveland,
Ohio; Houston, Texas; South Florida (including Fort Lauderdale, Miami,
and nearby areas); and Tampa, Florida. New Prudential Medicare members
were contacted three months after enrollment, and those meeting the eligi-
bility criterion were asked to complete an in-person survey. In order to be
included in the study, members had to be comfortable speaking either
English or Spanish, living in the community, and possess adequate visual
and cognitive function. The survey included the Short Test of Functional

APPENDIX B 257
Health Literacy in Adults (S-TOFHLA) (Parker et al., 1995), a series of

questions designed to measure health literacy. A detailed description of the
survey and data has been published elsewhere (Gazmararian et al., 1999).
Prudential administrative claims databases were used to compute an-
nual health expenditures from the date of enrollment for all eligible enroll-
ees by site of service (inpatient, outpatient, emergency room, and phar-
macy). The claims database includes costs for all medical services used by
enrollees associated with insurance reimbursement. The cost for each ser-
vice is the sum of Prudential’s reimbursement and the beneficiary’s out-of-
pocket payment.
Table B-1 presents evidence on how closely the study sample represents
the U.S. population of health-care consumers. The first column of the table
presents summary statistics for the 3,260 responders, the second for the
3,245 nonresponders, and the third for participants of comparable age in
the household component of the 1997 Medical Expenditure Panel Survey
(MEPS) (for a description see Cohen et al., 1996–1997). Differences be-
tween samples were assessed using one-way analysis of variance (ANOVA)
tests by group for three-sample comparisons of continuous variables and
chi-squared tests for two-sample comparisons of binary variables. ANOVA
tests for differences in the cost variables were performed on the natural
TABLE B-1 Representativeness of the Study Sample

Prudential
Responders Nonresponders MEPS 97 P-value
Inpatient costs $5,321 $4,512 $2,276 <0.01

Outpatient costs $1,837 $1,547 $1,203 <0.01
ER costs $131 $115 $124 <0.01
Pharmacy costs $677 $655 $743 <0.01
Age 72.8±6.4 73.3±6.8 74.6±6.8 <0.01
Schooling
12 years 34% no data 31% 0.03
>12 years 31% no data 28% 0.03
Need help
with ADLs 5% no data 9% <0.01
Need help with
IADLs 31% no data 16% <0.01
N 3,260 3,245 3,833
NOTE: Age row reports mean ± standard deviation.

258 HEALTH LITERACY
logarithm of costs to make the variable conform to the normality assump-

tion underlying the F-test.
Compared to nonresponders and the MEPS sample, responders in-
curred higher inpatient, outpatient, emergency room, and pharmacy expen-
ditures. There were also small differences in average age (0.5 years) and the
proportion with more than 12 years of schooling. Compared to MEPS
respondents, Prudential respondents were less likely to need assistance with
at least one activity of daily living but more likely to need assistance with at
least one instrumental activity of daily living. Differences in survey admin-
istration may account for some of these inconsistencies (Wiener et al.,
1990).
Spending differences between the Prudential population and the MEPS
sample, which is nationally representative, may reflect the fact that study
participants reside primarily in large urban areas, where reimbursement
rates tend to be higher. South Florida, one of the locales from which re-
spondents were drawn, is known to have the highest level of per beneficiary
Medicare spending in the country (Center for Evaluative Clinical Sciences,
1998). The study population may also differ in health status. While Medi-
care managed care plans tend to enroll a healthier mix of beneficiaries
compared to the traditional Medicare program (Hellinger and Wong, 2000),
managed care plans that offer generous prescription drug coverage or re-
quire little in the way of cost-sharing may attract beneficiaries with chronic
conditions. A final explanation for the cost differences is that MEPS fails to
capture a large portion of spending for Medicare beneficiaries due to re-
strictive sampling criteria (Selden et al., 2001).
Raw S-TOFLHA score were converted to a discreet categorical variable
for purposes of analysis (Baker et al., 1999). Persons scoring 67 and above
on the S-TOFHLA were classified as having “adequate” health literacy and
those scoring 66 or below were classified as having “inadequate” health
literacy. Previous studies have distinguished between a “marginal” health
literacy group, with scores between 56 and 66, and an “inadequate” group,
with scores 55 or below (Baker et al., 2000). This study combined data
from the marginal and inadequate groups to increase statistical power, as
no significant cost differences were found between these two groups in
preliminary analyses.
Table B-2 displays detailed summary statistics by health literacy level
for the responders. Differences between groups were assessed using chi-
squared tests for binary variables and t-tests for continuous variables. Per-
sons with inadequate health literacy had lower incomes and fewer years of
schooling. More Caucasian subjects had adequate than inadequate health
literacy, while more African Americans and Spanish-speaking Hispanics
had inadequate health literacy. Physical and mental quality-of-life, as mea-

APPENDIX B 259
TABLE B-2 Characteristics of the Study Sample

Literacy
Adequate Inadequate P-value
Age 71.6±5.6 75.1±6.9 <0.01

Female 58% 57% n.s.
Race
White 84% 61% <0.01
Black 7% 22% <0.01
Hispanic, English speaking 2% 2% n.s.
Hispanic, Spanish speaking 7% 14% <0.01
Other 1% 1% n.s.
Income
No response 14% 20% <0.01
<$10K 12% 29% <0.0
$10K–$25K 50% 42% <0.01
>$25K 24% 9% <0.01
Schooling
<8 years 7% 36% <0.01
9–11 years 15% 25% <0.01
12 years 38% 25% <0.01
>12 years 40% 14% <0.01
Smoking
Never 38% 55% <0.01
Former 49% 43% <0.01
Current 13% 12% n.s.
Drinking
None 59% 72% <0.01
Light to Moderate 37% 26% <0.01
Heavy 4% 2% <0.01
Physical health SF-12 score 46.4±10.7 42.6±11.8 <0.01
Mental health SF-12 score 55.6±8.0 53.1±10.4 <0.01
Chronic conditions
High blood pressure 45% 50% 0.01
Arthritis 50% 58% <0.01
Depression 6% 5% n.s.
N 2,094 1,166
NOTE: Age and SF-12 score rows report mean ± standard deviation; n.s. = not significant.
sured by SF-12 scores (Ware et al., 1996) and chronic condition indicators,
were higher in those with inadequate health literacy, indicating worse health
status overall. Somewhat surprisingly, persons with inadequate health lit-
eracy are less likely to smoke or have smoked previously and less likely to
consume alcohol.

260 HEALTH LITERACY
Statistical Analysis
Costs by site of service were compared between the adequate and inad-
equate health literacy groups using a two-part regression model of medical
spending. The two-part model is the standard statistical framework in em-
pirical health economics for measuring the impact an individual character-
istic on medical costs (Diehr et al., 1999). It is designed to account for the
unique distribution of medical spending found in most samples; a sizeable
minority of individuals do not use medical care, many use small amounts,
and a few individuals incur substantial medical bills that account for a large
percentage of aggregate spending. Because of the highly skewed distribu-
tion and presence of a large number of “0” values, standard statistical
methods that assume the dependent variable is normally distributed yield
inaccurate predictions of costs (Duan et al., 1983). The two-part model
attempts to more accurately mimic the empirical distribution of medical
spending by splitting the distribution into two parts and allowing the im-
pact of independent variables, such as health literacy, on the probability of
using medical care to be independent of their impact on the costs of medical
care for those who use it.
The first stage of the model measures the probability of using medical
care as a function of individual characteristics. Typically, logitistic or probit
regression is used, where the dependent variable equals one if costs are
strictly positive and zero otherwise. Probit (or probability unit) regression
was used in this case. Health literacy was included as an independent
variable, along with controls for age, sex, race, income, schooling, smok-
ing, and alcohol consumption. The second stage of the model estimates the
relationship between independent variables and costs among those who use
medical care. Parameters are estimated via least squares regression, where
the dependent variable is the logarithm of costs and the independent vari-
ables are the same as in the first stage but the sample includes only individu-
als who received care (i.e., those with strictly positive values for the relevant
cost category).
Coefficient estimates for the two-part model are difficult to interpret in
isolation, since the dependent variable of the second stage is in log, rather
than constant, dollars, and it is customary to state results in terms of
predicted spending levels. These are constructed by computing predicted
probabilities from the first stage and then multiplying these predicted prob-
abilities by the exponentiated second-stage predicted values and a “smear-
ing factor” (Duan, 1983), which is needed to transform logged dollars back
to constant dollars, and averaging the predicted spending levels over the
entire sample. Transforming log to constant dollars via this method may
produce misleading results if the variance of spending in the upper part of
the distribution differs from the variance in the lower part (Manning, 1998).

APPENDIX B 261
To address this issue, costs were also analyzed using the modified two-part
model proposed by Mullahy (1998). In this model, the first stage is the
same as in the standard two-part model, but the second stage is a nonlinear
equation where cost equals the exponentiated sum of dependent variables
and coefficients. This modified two-part model produced estimates within
5 percent of the predicted values from the standard two-part model. There-
fore, only the results from the standard two-part model are presented
below.
Two values are used to summarize the effect of a binary independent
variable on spending. The first is the average predicted spending level with
the variable indicating inadequate health literacy set equal to zero for every
respondent; the second is the average predicted spending level with the
health literacy variable set equal to one. Computed predicted values in this
manner nets out the impact of observable individual characteristics, such as
age, on spending.
Confidence intervals for predicted values were computed via simula-
tion; the first- and second-stage coefficients were drawn from their respec-
tive multivariate normal distributions and predicted values were computed
following the steps outlined above. Repeating this routine 1,000 times
produced distributions of predicted values, and the lower and upper bounds
of the confidence intervals were set equal to the 2.5th percentiles and the
97.5th percentiles of the distributions, respectively.
Two models were estimated. The first (or basic) model includes con-
trols for sex, age, income, schooling, smoking, and alcohol consumption.
The second includes additional controls for physical and mental status
(from the SF-12) and chronic conditions (high blood pressure, arthritis, and
depression). This model does not include the 66 observations for which no
physical or mental health SF-12 scores were reported, for a sample of 3,192
observations (= 3,260 – 66).
Results
Results from the two-part model are displayed in Table B-3. Inpatient
costs are the largest component of total medical spending. Predicted inpa-
tient spending for persons with inadequate health literacy is $993 higher
than that of persons with adequate health literacy (difference in raw means:
$1,859). Controlling for health status, predicted inpatient spending for
persons with inadequate health literacy is about $450 higher than that of
persons with adequate health literacy. The confidence intervals for inpa-
tient spending from the basic model overlap slightly, while the confidence
intervals for inpatient spending from the model that includes controls for
health status display a greater degree of overlap. Examining separately the
results from each stage of the two-part model helps illuminate the reasons

262 HEALTH LITERACY
TABLE B-3 Predicted Health-Care Spending

Health Literacy
Cost Category Adequate Inadequate Difference
Basic Model
Inpatient $5,093 [$4,593 – $5,656] $6,086 [$5,424 – $6,806] $993
Outpatient $1,910 [$1,816 – $2,017] $1,795 [$1,681 – $1,914] ($115)
Emergency room $110 [$97 – $124] $174 [$154 – $196] $64
Pharmacy $700 [664 – $739] $686 [$629 – $741] ($14)
Model with Controls for Health Status

Inpatient $5,352 [$4,832 – $5,945] $5,794 [$5,042 – $6,573] $442
Outpatient $1,989 [$1,881 – $2,118] $1,709 [$1,589 – $1,854] ($280)
Emergency room $115 [$102 – $130] $166 [$144 – $193] $51
Pharmacy $778 [$729 – $832] $695 [$633 – $765] ($83)
NOTE: 95% confidence intervals are in brackets. Difference column displays the mean cost in
the Inadequate column subtracted from the mean cost in the Adequate column. Negative
values are in parentheses.
for spending differences. According to the first part of the two-part model
for inpatient spending (results not shown; complete regression results are
available from the author upon request), persons with inadequate health
literacy are more likely to use inpatient services (p < 0.05), but, among
those who used inpatient care, spending did not differ by health literacy
status.
In contrast to the results for inpatient spending, the predicted outpa-
tient spending level from the basic model for persons with adequate health
literacy is higher than the predicted value for persons with inadequate
health literacy. Predicted spending on emergency room care is lower for
persons with adequate health literacy, while the predicted values for phar-
macy spending from the basic model are comparable.
These results are shown in terms of total spending by the study sample
in Table B-4. The first column shows predicted total spending under the
assumption that the proportion of individuals with adequate health literacy
is 64 percent, the actual proportion in the study sample. The second column
shows predicted total spending under the assumption that the proportion of
individuals with adequate health literacy is 100 percent, representing the
maximum attainable level of health literacy in the population.

APPENDIX B 263
TABLE B-4 In-Sample Prediction of Health Literacy and Total Costs

Percent with Adequate Literacy
64% (actual) 100% Difference
Inpatient 17,877,000 $16,616,000 $1,261,000

Outpatient 6,079,400 $6,227,300 ($147,900)
Emergency room 438,480 $359,910 $78,570
Pharmacy $2,263,400 $2,277,700 ($14,300)
NOTE: Difference column displays the mean cost in the inadequate column subtracted from
the mean cost in the adequate column. Negative values are in parentheses.
Discussion
When assessing the causality of the results presented in Tables B-3 and
B-4, it is important know whether health literacy, like ethnicity, is a con-
stant, fixed characteristic of individuals or, like income, is associated with
changes in health. Health literacy declines sharply with age in the study
cohort (Baker et al., 2000), suggesting the latter. If so, then the relationship
between health and health literacy is bidirectional; health literacy affects
health and vice versa. To take an extreme example, an individual who
experiences a severe stroke may lose the ability to read. It would be incor-
rect in such a case to attribute the costs associated with post-stroke care to
illiteracy, since the stroke caused illiteracy and not the other way around.
Controlling for health status, as is done in the extended model, removes the
effect of health on health literacy but also removes the effect of health
literacy on disease incidence, leading to estimates of the impact of health
literacy on spending that are systematically lower than the true effect.
Declines in health literacy by age are unrelated to the onset of chronic
conditions (Baker et al., 2000), suggesting that the bias due to reverse
causality is not large. Nevertheless, future studies could address this issue
by taking two or more measurements of health literacy from the same
respondent at different points in time.
Another caveat to this study is that though the analysis included fairly
extensive controls for individual characteristics, including income, educa-
tion, smoking, and alcohol consumption, there still may be unobserved
individual characteristics correlated with both health literacy and spending
that confound the results. For example, if individuals with low health lit-
eracy are also distrustful of the medical care system and are reluctant to
seek medical attention, then the results will understate the impact of health
literacy on costs.

264 HEALTH LITERACY
Some insight on the validity of these results may be gained by examin-

ing differences in spending by site of service. Studies have shown that
patients with low levels of health literacy receive fewer preventive services
(Lindau et al., 2002; Scott et al., 2002), frequently fail to follow medication
instructions (Andrus and Roth, 2002), and have worse health outcomes
(Schillinger et al., 2002). The results of this study are consistent with these
findings; individuals with inadequate health literacy make greater use of
services designed to treat complications and advanced cases of disease, as
indicated by higher spending for inpatient and emergency room care. Si-
multaneously, they use fewer services designed to manage disease, as evi-
denced by lower spending for outpatient care.
In conclusion, these results lend support to the hypothesis that indi-
viduals with low levels of health literacy incur higher medical costs, but,
because of the limitations discussed above, no definitive conclusions can be
drawn from the analysis. Results were sensitive to the inclusion of controls
for health status, and the confidence intervals around predicted inpatient
spending from the basic model overlapped by a small amount. Although it
is impossible to prove causality, future studies should take advantage of
statistical methods, such as propensity score estimators (Coyte et al., 2000;
Rubin, 1997), designed to estimate treatment effects efficiently and the
diagnostic information contained on claims to determine if expenditures
are higher for persons with the conditions thought to be most responsive to
patient knowledge. Data with repeated measurements of health literacy
over time would also be helpful, especially for assessing the responsiveness
of health literacy to health. For the time being, researchers should be cau-
tious in terms of justifying interventions to improve health literacy based on
potential cost savings.
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266 HEALTH LITERACY
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APPENDIX B 267
Improving Chronic Disease Care for Populations with

Limited Health Literacy
Dean Schillinger, M.D.

The problem with communication is the assumption that it has occurred.
—George Bernard Shaw
Introduction
Chronic disease management is one of the major challenges facing
health-care systems and patients in industrialized nations. Nearly three-
quarters of all health-care resources are devoted to the treatment of chronic
diseases, and nearly one-half of the U.S. population has one or more chronic
condition (Institute for Health and Aging, 1996). The collaboration be-
tween the system of care, providers, patients, and the community to provide
the best health outcomes adds a layer of complexity to the delivery of health
care to individuals with chronic disease. Effective disease management is
based on systematic, interactive communication between patients and the
providers and health system with whom they interact (Norris et al.,
2002a, b; Von Korff et al., 1997), all occurring in the context of a commu-
nity whose resources meet patients’ needs (Wagner, 1995).
This paper uses the definition of disease management provided by the
Task Force on Community Preventive Services, a nonfederal Task Force
convened in 1996 by the Department of Health and Human Services (HHS)
to provide leadership in the evaluation of community, population, and
health-care system strategies to address a variety of public health and health
promotion topics, and appointed by the Director of the Centers for Disease
Control and Prevention (Norris et al., 2002a, b). Disease management is an
organized, proactive, multicomponent approach to health-care delivery that
involves all members of a population with a specific disease, is focused on
the spectrum of the disease and its complications (including the prevention
of co-morbid conditions), and is integrated across the relevant aspects of
the delivery system.
The last few decades have seen tremendous advances in the care of
chronic conditions, including an array of new therapeutic options, risk-
factor modification for secondary prevention of co-morbid conditions, the
availability of home monitoring tools, and the growth of disease manage-
The research reported herein was supported, in part, through grants from the National
Center for Research Resources (K-23 RR16539), the Soros Open Society Institute, and The
Commonwealth Fund.

268 HEALTH LITERACY
ment programs (Bodenheimer, 1999; Diabetes Control and Complications

Trial Research Group, 1993, 1996; McCulloch et al., 2000; United King-
dom Prospective Diabetes Study Group, 1998). Despite these advances,
health quality and clinical outcomes of patients with chronic diseases vary
across sociodemographic lines (American Diabetes Association, 1998; CDC,
2000; Fiscella et al., 2000; Piette, 1999; Vinicor et al., 2000). Much of the
burden of chronic disease falls on the elderly and those of low socioeco-
nomic status, populations that have also been shown to have dispropor-
tionately high rates of health literacy problems (Gazmararian et al., 1999a;
Williams et al., 1995b). It is increasingly apparent that the health-care
system has not evolved to serve those with limited health literacy. The
prevalence of limited health literacy, compounded by a health-care system
in which scientific advances and market forces place greater technical and
self-management demands on patients and their families, may help to create
unequal outcomes despite what some consider equal access (IOM, 2001,
2003).
There currently is a lack of precision and uniformity regarding the
meaning of the term “health literacy” (American Medical Association, 1999;
Davis et al., 1991; HHS, 2000; Nutbeam, 2000) and little consensus as to
the extent to which literacy equates with health literacy (see Chapter 2 in
this report). There is general agreement, however, that (1) literacy and
numeracy skills are deeply embedded in the construct of health literacy and
(2) the problems associated with having limited health literacy are most
intense for those individuals with limited literacy skills. The ensuing discus-
sion in this chapter is based on these two assumptions.
The purpose of this article is to (1) briefly review the elements of the
most well-accepted model to restructure chronic disease care delivery, the
Chronic Care Model of Wagner and others (1995), (2) describe the ways in
which limited health literacy may lead to worse chronic disease outcomes,
(3) use the Chronic Care Model to consider opportunities to reduce health
literacy-related disparities, and (4) reflect on strategies to develop quality-
of-care indicators to promote improvement in chronic disease care for pa-
tients with limited health literacy.
The Chronic Care Model

Health-care delivery is poorly organized to meet the needs of patients
with chronic diseases. Rushed practitioners find it difficult to follow estab-
lished practice guidelines, limited coordination hampers multidisciplinary
care, inadequate training leaves many patients ill-equipped to manage their
illnesses, and lack of active follow-up leads to preventable deterioration in
function. Some managed care organizations and integrated delivery systems
have attempted to correct deficiencies in management of chronic diseases.

APPENDIX B 269
To guide the reorganization of chronic disease care, Dr. Ed Wagner and

others developed the Chronic Care Model (see Figure B-1), which summa-
rizes the basic elements for improving care in health systems at multiple
levels (Wagner, 1998, 2003). These include the health system, health-care
delivery system design, decision support, clinical information systems, the
community, and self-management support. For example, a community that
has the infrastructure and resources to facilitate patients’ self-care activities
(transportation to appointments, safe recreational spaces for exercise, ad-
equate produce for healthy food choices, opportunities for educational or
communal engagement); a health system that trains patients to be active
participants through self-management educational activities (such as group
medical visits or other organized, skill-building activities); a clinic that re-
structures its care delivery through multidisciplinary teams, planned visits,
or home visits; or a practice that uses disease registries to track patients’
progress, stratify intensity of care, promote outreach, and maintain conti-
nuity—all would represent efforts consistent with the Chronic Care Model.
Focusing on these components could foster interactions between patients
Community Health System

Resources and Policies Organization of Health Care
Self-management Decision Delivery Clinical

Support Support System Information
Design Systems
Informed, Prepared,
Productive Proactive
Activated Interactions
Patient Practice Team
Functional and Clinical Outcomes

FIGURE B-1 Model for improvement of chronic illness care.
SOURCE: Wagner (1998). Reprinted with permission of the American College of
Physicians.

270 HEALTH LITERACY
who take an active part in their care and providers who are backed up by
resources and expertise. The Chronic Care Model integrates the published
evidence in chronic disease management, including the importance of ex-
ecutive leadership and incentives to promote quality, systems to track and
monitor patients’ progress and support timely provider decision-making
(Piette, 2000), patient self-management training (Lorig et al., 1999; Von
Korff et al., 1997), and community-oriented care. Patients and providers
prepared in these ways are likely more able to engage in productive interac-
tions that promote system efficiency and patient well-being (Norris et al.,
2002a).
A growing body of research demonstrates that self-management prac-
tices and clinical outcomes in chronic disease care vary by patients’ level of
health literacy (Kalichman and Rompa, 2000; Schillinger et al., 2002; Wil-
liams et al., 1998b). The Chronic Care Model and similar comprehensive,
population-based disease management approaches may offer insights into
the ways in which limited health literacy affects chronic disease care and
identify potential points of intervention. Preliminary evidence from a small
randomized trial suggests that disease management strategies can reduce
health literacy-related disparities in diabetes care (Rothman et al., 2003)
and that tailoring communication to those with limited health literacy might
affect outcomes in chronic anticoagulation and diabetes care (Schillinger et
al., 2002, 2003b). However, we were unable to locate published results of
any comprehensive disease management systems specifically designed to
improve chronic disease care for individuals with limited health literacy.
Developing such a system would likely benefit not only those with limited
health literacy, but all chronic disease patients, as many of the barriers
faced by those with limited health literacy are also experienced, albeit it a
somewhat lesser extent, by those with adequate health literacy.
How Limited Health Literacy Affects Chronic Disease Outcomes

Limited health literacy has been shown to be associated with worse
health status (Weiss et al., 1992), higher utilization of services (Baker et al.,
1997, 1998) and worse clinical outcomes (Kalichman and Rompa, 2000;
Schillinger et al., 2002). Whether limited health literacy is a marker for
other determinants of health, such as socioeconomic status, or is in the
causal pathway to poor health is currently a matter of some debate. For
chronic disease care, which relies on self-management, self-advocacy, ongo-
ing monitoring, and interactive communication, it is reasonable to hypoth-
esize that health literacy may be one determinant of health outcomes.
Limited health literacy may affect many aspects of chronic disease care.
It may influence the interaction between provider and patient, impact the
ability of the health system to communicate successfully with the patient,

APPENDIX B 271
and affect the availability of community resources for chronic disease pa-
tients and their families (Figure B-2). By reviewing this framework, we can
begin to generate a set of priorities for targeted study and intervention that
reflects a blending of what we have learned from the Chronic Care Model
and what is known about empowering low-literacy adults from the field of
adult education (Roter et al., 1998, 2001).
Office-Based Clinician–Patient Communication

Much of chronic disease care takes place in the context of a medical
office visit. Communication about chronic diseases during outpatient visits
may be hampered by several factors. These include the relative infrequency
and brevity of visits, language barriers and limited literacy, differences
between providers’ and patients’ agendas and communication styles, lack
Social Policy
Health Health
Policy/Incentives Enhanced Policy/Incentives
Community
Factors
Improved • Access Expanded
Provider-Patient • health coverage Home-Based
Communication • provider availability Monitoring and
• Economic Resources Clinical Support
• Interactive, • Adult Education
Participatory • Environmental: • Patient and Family
Communication • nutrition Empowerment
• Open Discussion of • air quality • Good Self-Management
Explanatory Models • physical activity Practices
• Collaborative Goal • safety • Learning and Skill-Based
Setting • occupational risks Registries
• Patient Recall and • Trust in Health System • Decision Support and
Comprehension of • Power and Advocacy Problem-Solving Skills
Advice and Instructions • Public Health Messages/ • Ability to Navigate System
• Understanding of Health Promotion and Self-Advocate
Disease Processes and Activities • Maintaining Continuity
Treatment Options in Communication
• Trust • Self-Efficacy
Improved Clinical Outcomes

and Better Quality of Life
FIGURE B-2 Improving chronic disease care: a framework based on health litera-
cy and related research.

272 HEALTH LITERACY
of trust between the patient and provider, overriding or competing clinical

problems, lack of timeliness of the visit in relation to disease-specific prob-
lems, and the complexity and variability of patients’ reporting of symptoms
and progress of their disease.
Patients with chronic diseases and limited health literacy have been
shown to have less knowledge of their condition and of its management
(Williams et al., 1998a, b) often despite having received standard self-
management education. Patients with limited health literacy have greater
difficulties accurately reporting their medication regimens and describing
the reasons for which their medications were prescribed (Schillinger et al.,
2003b; Williams et al., 1995a; Win and Schillinger, 2003) and more fre-
quently have explanatory models that may interfere with adherence
(Kalichman et al., 1999). While patients with limited health literacy clearly
have problems with literacy and numeracy skills in the health-care setting,
patients also experience difficulties with oral communication. A recent study
among patients with diabetes demonstrated that those patients with limited
health literacy (as measured by the Short Test of Functional Health Literacy
in Adults [S-TOFHLA] [Nurss et al., 1995]) appear to have particular
problems with both the decision-making and the explanatory, technical
components of dialogue (Schillinger et al., 2004). Patients with limited
health literacy may also be less likely to challenge, ask questions of the
provider (Baker et al., 1996; Street, 1991), or disclose poor understanding
(Baker et al., 1996), and may cope by being passive or appearing uninter-
ested (Cooper and Roter, 2003; Roter, 2000; Roter and Hall, 1992; Roter
et al., 1997). Clinicians tend to underestimate the information needs of
patients (Cegala, 1997) and underuse interactive teaching strategies that
may be especially useful for patients with limited health literacy (Schillinger
et al., 2003b). Clinicians’ frequent use of jargon in clinical encounters may
be particularly problematic for patients with limited health literacy. This
jargon can range from technical jargon (words that have meaning only in
the clinical context, e.g., “glucometer”), quantitative jargon (words for
which clinical judgment is required to accurately interpret, e.g., “excessive
wheezing”), to lay jargon (words for which two meanings exist, one with
clinical meaning and the other with lay meaning, e.g., “your weight is
stable”). Clinicians are often unaware of the mismatch between their pro-
cess of giving information and patients’ process of recalling, understanding,
and acting on the information (Davis et al., 2002b; Doak et al., 1998;
Williams et al., 2002).
Home-Based Monitoring and Clinical Support

Chronic care involves an ongoing process of patient assessments, ad-
justments to treatment plans, and reassessments to measure change in pa-

APPENDIX B 273
tient health status. Without timely and reliable information about patients’
health status, symptoms, and self-care, the necessary health education, treat-
ments, or behavioral adjustments may come late or not at all. This can
compromise patients’ health and increase the likelihood of poor outcomes.
To best manage chronic disease, patients must remember any self-care
instructions they have received from their provider, be able to correctly
interpret symptoms or results of self-monitoring, and appropriately solve
problems regarding adjustments to the treatment regimen, as well as when
and how to contact the provider should the need arise. A number of studies
demonstrate that patients remember and understand as little as half of what
they are told by their physicians (Bertakis, 1977; Cole and Bird, 2000;
Crane, 1997; Rost and Roter, 1987; Roter, 2000) and the more informa-
tion provided, the less the patient is able to recall (Chow, 2003). Patients
with limited health literacy are likely to understand and remember at even
lower rates (Schillinger et al., 2004). In addition, they may be less equipped
to overcome gaps when they are at home due to knowledge deficits (Will-
iams et al., 1998a, b) and difficulties reading or interpreting instructions
(Crane, 1997; Williams et al., 1998b). Cross-sectional studies involving
patients with diabetes suggest that traditional self-management education
may not eliminate health literacy-related disparities in chronic disease out-
comes (Schillinger et al., 2002; Williams et al., 1998b).
Only a minority of clinical practices provide any form of care manage-
ment that involves outreach and support in the patient’s home (Casalino et
al., 2003). In addition, home-based disease-specific education, monitoring,
and clinical support increasingly rely on patients and providers interacting
via web-based or “e-health” interfaces (Robert Wood Johnson Foundation
and the National Cancer Institute, 2002). While these interfaces have been
suggested as a potential method of increasing interaction between patients
and providers (Robert Wood Johnson Foundation and the National Cancer
Institute, 2002), they may present overwhelming barriers to patients with
limited health literacy. Individuals with limited health literacy may have
trouble accessing the web (Fox and Fallows, 2003), difficulties reading
from web sites (Berland et al., 2001), and problems with navigation once
they get online (Robert Wood Johnson Foundation, 2002; Zarcadoolas et
al., 2002). Accreditation of health-related web sites (such as the Health on
the Net Foundation Code of Conduct) does little to improve readability of
diabetes web sites (Kusec et al., 2003).
Simply transforming text versions of disease-specific education to more
visually oriented media (i.e., CD-ROM), while associated with improve-
ments in satisfaction, does not appear to increase knowledge among pa-
tients with limited health literacy (Kim et al., 2001). Focus groups of pa-
tients with limited health literacy have identified health system navigation
(finding resources within the health system, such as knowing whom, for

274 HEALTH LITERACY
what, and when to call for assistance with a problem) as a particularly

daunting aspect of chronic disease management (Baker et al., 1996).
Community and Environmental Factors

Data from the National Adult Literacy Survey (Kirsch, 1993) demon-
strate regional variation in literacy rates that parallels neighborhood pat-
terns of socioeconomic status, immigrant status, age, and race and ethnicity.
Studies in health-care settings (Gazmararian et al., 1999b; Williams et al.,
1995b) indicate that patients with limited health literacy comprise a large
sector of patients in public hospitals and community clinics that predomi-
nantly serve socioeconomically disadvantaged populations, and in private
health systems that serve the elderly or those with low incomes, such as
Medicare and Medicaid managed care organizations. Little work has been
done exploring the relationship between limited health literacy and neigh-
borhood characteristics, particularly those of direct relevance to chronic
disease management. Recent work from social epidemiology (Berkman and
Kawachi, 2000) and literacy theory (Wallerstein and Bernstein, 1988) can
inform how community factors can either assist or hamper disease manage-
ment efforts for patients with limited health literacy. Communities that
have high rates of limited health literacy may be less able to assert political
power and advocate for the health and health-care needs of their commu-
nity (Nutbeam, 2000). Residents of medically underserved areas experience
greater difficulties accessing a regular source of health care, a problem that
has been shown to be associated with preventable hospitalizations for
chronic conditions (Bindman et al., 1995). Other environmental attributes
of communities, such as the availability of goods and services that promote
health, the quality of the air and recreational physical space, and occupa-
tional risks associated with neighborhood employment may each interact
with limited health literacy to lead to worse health. In addition, recent
studies examining disparities in quality of care demonstrate racial and eth-
nic differences in level of trust in the health-care system that may influence
how these communities interact with the health-care system (IOM, 2003).
Finally, the focus of health promotion messages and activities that take
place at the community level may not be aligned with the needs of patients
with limited health literacy (Nutbeam, 2000).
Shaping the Chronic Care Model for

Patients with Limited Health Literacy
One of the underlying assumptions of the Chronic Care Model is that
the reorganization of health care will lead to more productive interactions
between informed, involved patients, and prepared, proactive practice

APPENDIX B 275
teams, which will, in turn, lead to better outcomes (Figure B-1). In order for
this assumption to hold for populations with limited health literacy, we
need to think more critically about the ways in which we communicate
across the levels described above to ensure that interactions indeed are
productive. If we apply the Chronic Care Model without also attending to
the unique challenges to chronic disease management posed by limited
health literacy, we may improve care for many but run the risk of perpetu-
ating disparities in outcomes for those with limited health literacy.
In order to engage in more productive interactions with patients who
have limited health literacy, solutions must primarily affect the nature,
quality, and extent of communication. Previous research indicates patients
want practical, concise information focused on the identification of the
problem, what specifically the patient needs to do, why it is in their best
interest, and what outcomes they can expect (Davis et al., 2001, 2002a, b).
Communication strategies commonly employed by health professionals are
often only marginally effective for those with limited health literacy. At
present, clinicians do not have the means to uncover how patients learn
best, nor the tools to more effectively engage patients who do not appear to
be maximally benefiting from clinical interactions. In order to support
patients’ acquisition of self-management skills and increase confidence to
carry out self-management tasks, efforts should be made to develop tools to
assess how patients learn in the clinical setting, and to expand the repertoire
of options to match patients’ learning style or preferences. Some principles
derived from the field of adult education may be relevant to chronic disease
communication (Brookfield, 1986; Roter et al., 2001; Wallerstein, 1992).
Learners (patients) should be involved in developing health education mes-
sages, materials, and programs (Davis et al., 1998a, b; Rudd and Comings,
1994). Learning should be participatory; patients should be actively in-
volved in setting the agenda or curriculum and, at times, even leading it so
as to ensure relevance (relating and reflecting on experience), encourage
ongoing involvement, promote the development of behavior change through
critical thinking (thoughtful action), and support other learners to succeed.
This involvement will help ensure the education is relevant, understand-
able, culturally sensitive, and empowering. Interactions should involve ex-
ploration and problem-based learning (Cooper et al., 2003). Patient educa-
tion activities should be designed so as to engage patients in ways relevant
to their lives and their conditions and that enhance problem-solving skills
(Center for Literacy Studies, 2003). Such activities educational focus may
lead to patient-generated goal-setting, an important intermediate objective
in successful chronic disease care (Anderson, 1995; Anderson et al., 1995).
Group medical visits, an innovation in which groups of patients who share
a common condition regularly meet with a health provider, have the poten-
tial to operate via these principles. Results of a small trial with diabetes

276 HEALTH LITERACY
patients suggests that, when designed with the collaboration of an expert in

adult education, such visits can dramatically improve outcomes (Trento et
al., 2001, 2002).
As chronic disease education, monitoring, and clinical support move
beyond the office walls to include e-health and other forms of telemedicine,
it is critical that patients with limited health literacy are not left behind
(Robert Wood Johnson Foundation and the National Cancer Institute,
2002). Individuals with limited health literacy must be involved in all stages
of intervention design and testing. This participatory development method
allows for input during the generative phase of an intervention, provides
opportunities for feedback during multiple points of pilot testing, and can
engender trust and participation during the evaluation phase (Houts et al.,
1998; Jacobson et al., 1999). As an example, our recent work at San
Francisco General Hospital involves the development of an automated tele-
phone diabetes management system for patients with limited health lit-
eracy. The idea for a telephone-based intervention was generated, in part,
from patients. The program was developed with the active involvement of
adult learners and patients with limited health literacy, which significantly
altered numerous aspects of the program. Patients wanted to hear that we
are actively listening and care about their well-being. They preferred narra-
tive instead of instruction-based health education. Patients recommended
we reduce the speed with which messages are delivered and limit the amount
of technical language in order to make the messages more understandable.
We are currently evaluating the effect of this system on diabetes-related
outcomes.
If all patients with chronic diseases are to benefit from emerging tech-
nologies, particularly interventions that involve the Internet, research must
explore how to best design such programs for patients with limited health
literacy (Robert Wood Johnson Foundation and the National Cancer Insti-
tute, 2002). Such research will also require professional collaboration be-
tween disciplines such as computer science, health communication, educa-
tion, economics, marketing, sociology, and library and information science.
If we are to redesign the health-care delivery system and better support
patients in their self-management, it is important to recognize the needs
that patients with limited health literacy have expressed with regards to
system navigation. We must better understand the elements of successful
system navigation and apply this understanding to support patients’ navi-
gation and self-advocacy skills, and better equip patients to get what they
need from a complex system. We need to partner with patients with limited
health literacy to identify those aspects of the system that represent bottle-
necks and to design solutions that lower such barriers.
A crucial component to reducing the burden of limited health literacy
lies with the providers of health care. In order to boost provider prepared-

APPENDIX B 277
ness, we need to prime the workforce to more effectively care for patients
who have chronic diseases and limited health literacy. Training of all health
professionals that focuses on communication strategies to enhance clinician
self-awareness (Frankel and Stein, 2001), mutual learning, partnership-
building, collaborative goal-setting, and behavior change for chronic dis-
ease patients is essential (Wagner, 2003; Youmans and Schillinger, 2003).
Such training should be expanded to include all members of the multidis-
ciplinary health team, including lay health educators, both as learners and
teachers. These efforts must be informed by new health communication
research that involves patients with limited health literacy, a segment often
under-represented in clinical research.
Community efforts should focus on developing relationships that foster
trust, providing resources to measure and meet community needs, and
ultimately preparing members of a community to effectively advocate for
the needs of their community (Figueroa et al., 2002). Public health mes-
sages should take into account the health literacy skills of the population to
whom the message is being targeted, involve the population from the begin-
ning, and make use of appropriate channels to convey these messages (Bird
et al., 1998).
Measuring Progress
In order to promote progress in chronic care delivery for patients with
limited health literacy, quality-of-care measures must be designed to cap-
ture health literacy-related performance. If incentives are aligned to im-
prove quality, such measures of health-care quality can, in turn, lead to the
creation of standards of care and improve practice. There are several pos-
sible approaches to measuring the extent to which health systems are
meeting the needs of patients with limited health literacy. An indirect
approach, advocated by those involved in initiatives to reduce racial and
ethnic disparities in quality of care (IOM, 2003; Sehgal, 2003) is to use
existing measures of quality, such as Medicaid Health Plan Employer Data
and Information Set indicators (that currently do not include any health
literacy-specific indicators), and stratify a system’s performance by race or
ethnicity, or, in this case, health literacy level. Such an approach would
enable a comparison of performance in process or outcome measures
among those with inadequate health literacy in comparison to those with
adequate health literacy. A health system can be considered improving if
overall performance is improving and if the extent of health literacy-
related variation in performance is narrowing over time. The main chal-
lenge to this strategy is the complexity involved in measuring health lit-
eracy. Current instruments take between 3 and 7 minutes and require in-
person administration (Baker et al., 1999). Education level is not a useful

278 HEALTH LITERACY
proxy for health literacy, as there is only a modest correlation between

education and health literacy. There also are interactions between educa-
tion and other demographic characteristics (e.g., ethnicity, age, primary
language) on health literacy (Beers et al., 2003; Guerra and Shea, 2003). A
recent study suggests that a single questionnaire item may have reasonable
sensitivity and specificity in detecting inadequate health literacy and ap-
pears to perform well if the prevalence of inadequate health literacy in the
population is high enough (Chew and Bradley, 2003). In order for a strat-
egy of reducing health literacy-related disparities by measuring health lit-
eracy-related quality is to succeed, research to develop a rapid and reliable
measure of health literacy is needed.
A second approach is to develop novel measures of quality that may be
less disease-specific, yet have particular relevance to patients with limited
health literacy across chronic conditions. To our knowledge, relatively
little work has been done in this regard. For example, the National Center
for Quality Assurance (NCQA) for managed care organizations has cre-
ated standards regarding the readability of the patient appeal of denial of
services form (NCQA, 2003). While arguably of importance, the approach
of assessing quality by measuring document readability is obviously nar-
row in scope, and does not capture a more comprehensive view of the
patient experience. Other possibilities include measuring patients’ reports
of their experiences of communication (Schillinger et al., 2004), rates of
discordance between patients’ and providers’ reports of medication regi-
mens (Schillinger et al., 2003a), the extent to which home monitoring and
support for chronic disease is available (Norris et al., 2002b), the range of
learning options and media available to patients, the ease with which one
can navigate a health system, or capturing the degree to which a health
system has a family and community orientation (Starfield, 1998). In order
for significant progress to be made, it is essential that research is done to
develop appropriate quality indicators for health literacy-related perfor-
mance.
CONCLUSIONS
Despite wide variation in literacy levels, our society places high literacy
demands on its members. It is apparent that attempts to reduce health
literacy-related disparities must revolve around either directly addressing
the problem of basic literacy and/or creating a health-care system in which
the gap between the literacy demands of the system and the literacy skills of
the patients it serves is significantly narrowed. Modern chronic disease care
requires that patients play an active role in their care, and that clinicians
and the health systems in which they work take on the challenge of partner-
ing with patients to promote successful outcomes. Meeting these goals is

APPENDIX B 279
often most challenging for those patients who have the greatest need. When
considered as a barrier to successful health communication as well as a
marker for problems with navigation and self-advocacy, it becomes clear
that the concerns related to limited health literacy are inescapably linked to
the challenges of chronic disease management. In order to ensure that the
Chronic Care Model and increasingly sophisticated chronic disease man-
agement programs can benefit patients with limited health literacy, atten-
tion must be paid to tailor design and implementation with the involvement
of patients with limited health literacy, and to expand the reach of such
programs. By promoting meaningful, collaborative communication between
patients and the providers and systems that serve them, such a reorganiza-
tion is likely to benefit all patients with chronic diseases.
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APPENDIX B 285
Outside the Clinician–Patient Relationship:

A Call to Action for Health Literacy
Barry D. Weiss, M.D.
Many governmental, corporate, and nonprofit businesses, organiza-

tions, and agencies have, or should have, an interest in the health literacy
problem—because limited health literacy is prevalent in the groups for
which these entities are responsible. These entities can be broadly catego-
rized as insurers, employers, and advocacy groups.
Insurers should have an interest in the health literacy problem because
they pay for the medical care provided to individuals with limited literacy
skills, and these individuals have higher illness rates and higher health-care
costs than the population in general. Employers should care about literacy
because they pay for the health insurance of their workers who have limited
literacy skills, and they also lose worker productivity as a result of their
employee’s limited literacy. Advocacy groups should care about the literacy
problem because limited literacy skills often prevent their constituents from
achieving full potential in society. Methods by which these and other orga-
nizations and systems might help improve America’s health literacy issue
are shown in Table B-5, below.
Insurers
Several entities provide medical insurance coverage groups in which
low literacy is most prevalent. They include the publicly funded Medicare
and Medicaid programs and the military’s Tricare program.
Medicare
The Medicare program is a federally funded program that provides
health insurance benefits to most elderly U.S. citizens. Medicare’s costs are
heavily influenced by limited health literacy because of the high rate of
limited literacy skills among elderly individuals. According to the Centers
for Medicare and Medicaid Services, around 35 million persons over 65
years old currently receive Medicare benefits, and the number of beneficia-
ries increases annually (Figure B-3).
Federal expenditures for the Medicare program now exceed $240 bil-
lion per year for medical benefits, administrative costs, and program integ-
rity costs, representing some 20 percent of all health-care spending in the
country. These costs will all increase as the number of beneficiaries contin-
ues to grow (Figure B-4) (CMS, 2002).

286 HEALTH LITERACY
TABLE B-5 How Organizations and Systems Might Act to Improve

America’s Health Literacy
Insurers
• Provide insurance premium discounts and/or co-payment waivers to non-high school
graduates who enroll in and successfully complete graduate equivalency diploma
(GED) programs.
• Medicaid and Medicare could provide health education on common health problems
to their enrollees at community-based courses and seminars around the nation.
• Tricare could sponsor health education seminars around the nation for military
personnel and their dependents.
• Medicare, Medicaid, and Tricare insurance plans could all partner with community-
based literacy enhancement programs, such as those operated by ProLiteracy, to
provide literacy enhancement education to enrollees in those insurance plans.
Employers
• Partner with public school systems to enhance general literacy and biological science
and health education in elementary and secondary schools.
• Partner with community-based literacy enhancement programs (e.g., ProLiteracy) to
expand availability of such programs, many of which are currently oversubscribed
and cannot meet community needs.
• Expand workplace literacy education programs to include an emphasis on health
literacy.
• Fast food restaurants could provide education to employees regarding modes of
transmission of infectious disease, thus improving both employees’ health literacy
and sanitation in restaurants.
Advocacy Organizations
• Advocacy organizations for the elderly could provide health education courses and
classes on common health problems of older persons, specifically designed for
seniors with limited literacy skills.
• Professional advocacy organization could create a nationwide corps of volunteer
physicians and other health professionals to teach health education and prevention
topics in elementary and secondary schools across the nation.
• Professional health advocacy organizations could establish a well-publicized
national health literacy bee, analogous to current national spelling or geography
bees, in which children and adolescents would compete to demonstrate their
knowledge of health information.
Governmental and Social Service Agencies

• Public housing facilities for the poor could provide health education videotapes for
residents to view in their homes.
• Head Start and similar daycare programs could provide pediatric health education
information to parents of enrolled children.
• Homeless shelters could provide health education.
• Homeless shelters could link with community-based literacy programs to facilitate
entry of clients into those literacy programs.

APPENDIX B 287
TABLE B-5 Continued

• Provide health information—perhaps via live speakers and/or video presentations—
to individuals visiting agencies at which waiting times are typically extensive—e.g.,
motor vehicle department, welfare offices, post offices, etc.
• Prison systems could expand current inmate education programs to include greater
emphasis on health topics.
Others
• Assisted living centers for the elderly could provide health education videotapes for
residents to view in their homes.
• Health education messages could be displayed on the inside or bathroom stall doors
in all public restrooms.
• Health messages, perhaps in quiz form, could be displayed on movie theater screens
for the audience to view while waiting for the movie to begin.
• Sports celebrities could appear on national media to promote important health
issues.
• Cell phone display screens could provide a “health tip of the day.”
40
30
Millions
20
10
0
1980 1984 1986 1990 1996 1999
Year
FIGURE B-3 Number of Medicare enrollees.

SOURCE: Number of Medicare Enrollees, by Age of Enrollee: Selected Calendar
Years July 1, 1980–1999. Center for Medicare & Medicaid Services, Office of
Information Services (http://hcms.hhs.gov/review/supp/table7b.pdf).

288 HEALTH LITERACY
$300
$250 $241
$211
$200
Dollars in Billions
$150 $132
$100 $81
$50
$50
$23
$9
$3
$0
1967 1972 1977 1982 1987 1992 1997 2001
Fiscal Year
FIGURE B-4 Federal spending for Medicare. Note that overall spending includes
benefit dollars, administrative costs, and program integrity costs (federal spending
only).
SOURCE: Medicare Program Spending. Centers for Medicare and Medicaid Ser-
vices, Office of the Actuary, June 2002 (http://www.cms.hhs.gov/charts/default.asp).
By combining Medicare expenditure figures with results from the Na-

tional Adult Literacy Survey (NALS), which indicate that 80 percent of
persons over 65 have limited literacy skills, one can estimate that about 80
percent of Medicare beneficiaries—32 million individuals—have limited
literacy skills. Thus, most of the $240 billion annual Medicare expenditures
are related to providing benefits for persons with limited literacy. Address-
ing the health literacy of Medicaid enrollees (Table B-5) can potentially
result in substantial cost savings for the Medicare program.
Medicaid
The Medicaid program, funded by state and federal tax dollars, pro-
vides medical insurance benefits for about 45 million persons, most of
whom are poor (CMS, 2000). Total expenditures by the Medicaid system
were $175 billion per year in 1998, accounting for about 15 percent of all
health-care spending in the United States (Health Care Financing Adminis-
tration, 2000). The cost of the Medicaid program is expected to grow to
$444 billion by 2010 (Figure B-5).

APPENDIX B 289
Spending is projected to grow to $444 billion in FY 2010
500 FY 2010
Share
Total = $444
State Federal
400
Expenditures ($, billions)
300
200
100
0
1998 2000 2002 2004 2006 2008 2010
Fiscal Year
FIGURE B-5 Predicted Medicaid expenditures.

SOURCE: Health Care Financing Administration. A Profile of Medicaid: Chart-
book 2000, Section III. Medicaid Expenditures. Pp. 27–51 (http://www.cms.hhs.
gov/charts/medicaid/2Tchartbk.pdf).
The rate of limited literacy is high among Medicaid enrollees. A study

of a random sample of Medicaid enrollees in Arizona (Weiss et al., 1994)
found that the mean literacy skills of the enrollees were at just over grade-
level 5. More than a quarter of subjects had reading skills at or below the
fourth-grade level, in contrast to the eighth-grade average reading level of
U.S. adults. Subjects in the study who indicated that their preferred lan-
guage for reading was Spanish had their literacy skills assessed in Spanish,
and their average reading level was at grade level 3.1.
The limited literacy skills of Medicaid enrollees are associated with
high health-care costs. Indeed, in the Arizona study Medicaid recipients
with the highest reading levels had average annual health-care costs of
$2,969, similar to the $2,400 average cost of health care for all U.S. citizens
at the time of the study. In contrast, those with reading levels at or below
grade-level 3 had annual health-care costs averaging $10,688 (Weiss and
Palmer, 2004). These results are remarkable, given that the subjects had
relatively homogenous sociodemographic characteristics (all poor and un-
employed or employed at very low-paying jobs), and the statistical relation-

290 HEALTH LITERACY
ship between literacy and costs remained strong even after a multivariable
analysis that accounted for education, gender, ethnic group, and preferred
language. Thus, to the extent that interventions to improve health literacy
(Table B-5) can reduce health-care costs, such interventions can potentially
result in substantial cost savings for Medicaid programs.
Tricare
The Tricare program provides health insurance benefits for the nation’s
military personnel (active- and non-active-duty) and their dependents. The
program covers direct medical care, prescriptions, dental care, and a variety
of other health-related benefits.
Tricare is an expensive program. Spending by the federal government
for direct medical and administrative costs totaled $8.3 billion in 1998 for
some 4 million Tricare enrollees (Stoloff et al., 2000).
As noted earlier, many military recruits have limited literacy skills.
Given the association between limited literacy and higher health-care costs,
and given the cost of the Tricare system, significant cost savings might
accrue to the U.S. military if the health literacy skills of the military recruits
were improved. Thus, the military is an entity with large potential gain
from improvement in its members’ health literacy.
As mentioned, the military currently engages in literacy-skill enhance-
ment for its recruits to enable them to function adequately in the roles as
soldiers. Incorporating health knowledge within literacy training (Table
B-5) might provide further benefit by reducing excess costs related to
limited health literacy.
Employers
Business leaders have long recognized the need for literacy enhance-
ment in the workforce, as workers’ limited literacy skills often interfere
with productivity and safety (Rockefeller Foundation Conference Proceed-
ings, 1989). This concern is of particular importance for businesses that
employ large numbers of routine service providers and production workers,
because these groups have an over-representation of undereducated indi-
viduals (Reich, 1992). Some large employers already offer literacy training
to their employees to address concerns about workplace literacy (Academy
of Human Resource Development, 2000; Askov and Van Horn, 1993;
National Institute for Literacy, 1994).
Businesses should also have an interest in health literacy because of its
relationship to health-care costs. Government agencies have reported that
nearly two-thirds of Americans under age 65 obtain health insurance
through their workplace (Monheit and Vistnes, 1997), with more than 150

APPENDIX B 291
million workers and dependents in the United States, and an additional 5

million retirees, receiving job-based health insurance benefits (Gabel et al.,
2000). On average, health benefits currently cost employers about $1.29
per hour per employee (U.S. Department of Labor, 2002).
The result of these costs, based on recent data from the Agency for
Healthcare Research and Quality (AHRQ), is that each year private em-
ployers in the United States pay in the range of $350 billion to cover the
cost of hospitalizations and physicians’ services for their employees and
families (Table B-6) (AHRQ, 2000). Public employers, including federal,
state, and local governments, pay approximately $60 billion dollars per
year. These costs rise annually—an 8 percent increase in 2000 and an 11
percent increase in 2001—with similar increases anticipated in the future
(Mercer, 2003). Health insurance premiums paid by employers increase at
a faster rate than wages or overall inflation (Gabel et al., 2001). Indeed, the
Health Care Financing Administration has estimated that by 2008, health-
care spending in the United States will reach $2.2 trillion (CMS, 2003).
To the extent that improving literacy skills will reduce health-care
costs, employers would benefit substantially from initiatives that improve
worker literacy. This is especially true for employers with a workforce that
includes large numbers of routine service and production workers, as these
groups have high rates of limited literacy. Partners in such initiatives could
TABLE B-6 National Totals for Enrollees and Cost of Hospitalization

and Physician Service Health Plans for the Private Sector, United States,
2000
Enrollee Category Total (in thousands of persons)
Total Enrollees 71,253

Active enrollees 64,284
Enrollees through COBRA 2,766
Retired enrollees 4,203
Costs Total (in millions of dollars)
Total Costs 349,612

Employer contribution single coverage 69,066
Employer contribution family coverage 191,916
Employee contribution single coverage 18,251
Employee contribution family coverage 70,379
SOURCE: Agency for Healthcare Research and Quality, Center for Cost and Financing Stud-
ies. 2000 Medical Expenditure Panel Survey—Insurance Component (http://meps.ahrq.gov/
MEPSDATA/ic/2000/Tables_IV/TableIVA1.htm).

292 HEALTH LITERACY
include not only employers, but also community-based literacy programs

and local governments seeking to attract employers that would be drawn to
communities with a more literate workforce.
An additional approach to improving workforce literacy, including
health literacy, could focus on science education in secondary schools and
universities, where most students currently are taught basic science facts,
rather than applied health sciences—and many students study little or no
science at all. Indeed, data from the National Center for Education Statis-
tics indicate that only 75 percent of U.S. high school students take more
than one science course. While biology is the most popular science course
offered in high school (i.e., most students select biology as their one science
course), only about 1 in 6 takes an advanced course in biology (National
Center for Education Statistics, 2001). The result is that many, if not most,
students, even some destined for a career in the health sciences, graduate
from high schools without a substantive understanding of the anatomy,
physiology, and etiology of common diseases like atherosclerosis, diabetes,
and cancer. Incorporating an applied “health literacy approach” into sci-
ence education in schools and universities could have a major benefit for
improving the health literacy of the nation’s workforce and for reducing
health-care expenditures for employers (Table B-5).
Advocacy Organizations
There are many national-level organizations with missions dedicated to
improving opportunities and quality of life for their constituents. Of note,
some of these organizations advocate on behalf of the groups with the
highest rates of limited literacy—the elderly, Hispanics, and African Ameri-
cans—and these organizations could implement programs to improve their
constituents’ health literacy (Table B-5). Although not discussed here, there
are also advocacy groups on both local and national levels that represent
the other high-risk groups, such as other ethnic minority groups, immi-
grants, the homeless, the poor, and prisoners.
Advocates for the Elderly

The most well known, and perhaps the most important, senior citizens’
advocacy group is the American Association of Retired Persons (now known
only by the acronym AARP)—which represents over 35 million older Ameri-
cans (AARP, 2002). In addition to general advocacy on behalf of the
nation’s elderly, AARP places particular emphasis on health and the cost of
health care for senior citizens.
Given the very high rate of limited literacy among older individuals,
and relationship of those limited literacy skills to health status, health-care

APPENDIX B 293
costs, employment opportunities, and quality of life, a focus on literacy—

including health literacy—would advance AARP’s mission and improve
quality of life for its constituents. Other senior citizens’ advocacy groups
share similar goals.
Advocates for Hispanics

There are many advocacy organizations for Hispanics, but two stand
out as particularly respected and influential: the National Council of La
Raza and the Mexican American Legal Defense and Educational Fund. In
addition, the National Hispanic Medical Association has particular interest
in health-related issues, which could include health literacy.
National Council of La Raza

The National Council of La Raza is a private, nonprofit organization
established in 1968. It has 270 formal affiliates in 40 states, and a much
broader network of 20,000 groups and individuals nationwide. Its mission
is to “improve life opportunities for Hispanic Americans” (National Coun-
cil of La Raza, 2003). Life opportunities are diminished when individuals
have limited literacy skills, and the literacy skills of Hispanics are currently
the lowest of any major ethnic group in the United States (Table B-7).
Enhancing literacy skills, including health literacy skills, as an area of em-
phasis for the National Council of La Raza and similar organizations has
the potential to improve economic opportunities and health care for His-
panic Americans.
Mexican American Legal Defense and Educational Fund

The Mexican American Legal Defense and Educational Fund is a na-
tional nonprofit organization whose mission includes assuring that “there
are no obstacles preventing [the Latino] community from realizing its
dreams . . .” (Mexican American Legal Defense and Educational Fund,
2003). Limited literacy is one such obstacle, and the Mexican American
Legal Defense and Educational Fund could participate in efforts to enhance
literacy and health literacy skills of Hispanics.
National Hispanic Medical Association

The National Hispanic Medical Association is an organization that
represents Hispanic medical providers. The organization expresses a com-
mitment to providing policy makers and health-care providers with expert
medical information, and to supporting and strengthening delivery of health

294 HEALTH LITERACY
TABLE B-7 Percentage of Adult Population Groups with Literacy Skills

at NALS Levels 1 or 2
Percent
Group Level 1 Level 2
All NALS Respondents 22 28

Age
16–54 years 15 28
55–64 years 28 33
65 years and older 49 32
Highest Education Level Completed
0–8 years 77 19
9–12 years (no high school graduation) 44 37
High school diploma/GED (no college study) 18 37
Racial/Ethnic Group
White 15 26
American Indian/Alaska Native 26 38
Asian Pacific Islander 35 25
Black 41 36
Hispanic (all groups) 52 26
Immigrants to U.S. (various countries of origin)
0–8 years of education prior to arrival in U.S. 60 31
9 + years of education prior to arrival in U.S. 44 27
SOURCE: Unadjusted averages of prose and document literacy scores on the NALS as re-
ported on Tables 1.1A, 1.1B, 1.2A, and 1.2B in Kirsch I, Jungeblut A, Jenkins L, Kolstad A.
Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey.
Washington, DC: National Center for Education Statistics, U.S. Department of Education;
September, 1993, and on Table B3.13 in U.S. Department of Education. National Center for
Education Statistics. English Literacy and Language Minorities in the United States, NCES
2001–464, by Greenberg E, Macías RF, Rhodes D, Chan T. Washington, DC: 2001.
services to Hispanic communities across the nation (National Hispanic

Medical Association, 1997). Aiding in the improvement of health literacy
for Hispanics would go hand in hand with these goals, and it would seem
logical for the National Hispanic Medical Association to participate in
health literacy efforts.
Advocates for African-Americans

African-Americans are also represented by a number of advocacy orga-
nizations. Two of the most respected organizations are the National Asso-
ciation for the Advancement of Colored People (NAACP) and the National
Urban League. The National Medical Association, the organization that

APPENDIX B 295
represents African-American physicians, also has a specific interest in the

health status of African-American citizens.
NAACP
NAACP is the nation’s oldest and largest civil rights organization.
NAACP has a specific health division, with goals that include “developing
national health advocacy and education initiatives that promote equity in
health status,” “sponsoring collaborative initiatives with other national
and local health groups,” and “expanding outreach on health advocacy and
awareness in communications” (NAACP, 2003). Assuring adequate health
literacy as a component of initiatives meets all of those goals, and NAACP
may thus be an effective advocate for enhancing health literacy among
African Americans.
National Urban League

The National Urban League has affiliates in more than 100 cities in 24
states. While the organization’s goal is broadly aimed at enabling “African
Americans to secure economic self-reliance, parity and power and civil
rights,” its mission also includes a specific goal of “ensuring that our chil-
dren are well educated” (National Urban League, 2002). Efforts to improve
literacy in general, and health literacy in particular, would fall within the
mission of the National Urban League.
National Medical Association

The National Medical Association represents the interests of more than
25,000 African-American physician and their patients. One of the organiza-
tion’s key missions is “to improve the status of health and quality and
availability of health care to African-American and underserved popula-
tions” (National Medical Association, 2003). This mission would be en-
hanced by efforts to improve health literacy.
Other Organizations and Systems

There are many other organizations and systems that provide services
to groups with high rates of limited literacy. Among these are prison sys-
tems and social service agencies that work with undereducated individuals.
Professional organizations that represent health-care providers (in addition
to the National Medical Association and National Hispanic Medical Asso-
ciation) also have a role to play in improving health literacy (Table B-5).

296 HEALTH LITERACY
Prison Systems
Inmates in most prisons already have access to literacy improvement
programs. Given the large and growing size of the U.S. prison population,
however, and the costs associated with providing health care to prisoners,
incorporating health literacy content might enhance current literacy im-
provement programs.
Social Service Agencies

Social service agencies in virtually all U.S. communities interact with
low-literate individuals every day, because clientele of these agencies in-
clude large numbers of unemployed persons with limited education. Some
of these agencies, particularly adult education programs, focus on literacy
enhancement as a core mission through adult basic education, GED pro-
grams, and “English as a Second Language” programs.
The majority of individuals with limited literacy, however, do not enter
such education programs. Rather their interaction with social service agen-
cies is often through county and state public assistance programs, unem-
ployment agencies, childcare programs, and others. These social service
agencies spend large sums of money providing services to their clientele,
and those sums might be reduced if clientele had better literacy skills that
permitted easier entry into the workforce. To the extent that clientele of
these agencies have chronic health problems—and many do—costs might
further be reduced if clientele had better health literacy.
Public assistance, unemployment, and childcare agencies could link
with local adult education programs, or with national literacy programs
such as ProLiteracy America (Proliteracy Worldwide, 2002), to facilitate
easy referral into literacy training programs. In fact, literacy training pro-
grams could be located on site with, or in close geographic proximity to, a
variety of social service agencies, including medical clinics whose clients
might benefit from literacy enhancement. Such partnerships, some empha-
sizing health literacy, are currently in place in a number of com-
munities (Community Health Partners, 2003; El Paso Community College/
Community Education Program, 2001). More such partnerships should be
encouraged.
Professional Associations
Finally, professional associations representing health-care providers
have an interest in assuring and improving health and health care for indi-
vidual patients. With evidence showing that limited literacy skills are asso-
ciated with poorer health status, all professional associations representing

APPENDIX B 297
health-care providers should have a de facto interest in improving health

literacy.
Some professional associations, such as the American Medical Associa-
tion, have already produced educational materials to enhance health pro-
viders’ understanding of the health literacy problem and give them sugges-
tions for how to more effectively communicate with patients (Weiss, 2003).
The materials include educational monographs and videotapes, train-the-
trainer programs, and outreach efforts to local medical societies. Other
professional organizations, such as the American Academy of Neurology,
the Virginia Medical Society, the Iowa Medical Society, and the Georgia
Academy of Family Physicians have also developed programs, or are plan-
ning to do so.
Additional efforts from professional associations could include lobby-
ing efforts aimed at securing support for health literacy content in adult
basic education programs. Finally, professional organizations could im-
prove the public’s health literacy by working with school systems to de-
velop and implement health education curricula for use in elementary and
secondary schools.
CONCLUSION
The unique vocabulary and concepts of medicine make it difficult for
many individuals to fully understand health information provided to them
by clinicians. This lack of understanding translates into poor health lit-
eracy—i.e., a limited ability to read, understand, and use health informa-
tion to make effective health-care decisions and follow recommendations
for treatment. While limited health literacy occurs in all segments of soci-
ety, it is a particular problem for individuals with limited reading skills (i.e.,
limited general literacy).
Limited literacy is more prevalent in certain groups. These groups in-
clude the elderly, racial and ethnic minorities, persons with limited educa-
tion, immigrants, prisoners, the poor and homeless, and military recruits. In
some of these groups, such as the elderly, certain ethnic minorities, and
persons who did not complete school, the prevalence of limited literacy
exceeds 80–90 percent.
Persons with limited general and health literacy, on average, have
poorer health knowledge, poorer health status, and higher health-care costs
than do persons with higher-level literacy skills. The relationship between
limited literacy and poorer health and higher costs is strong and indepen-
dent of other socioeconomic factors.
Based on results of the NALS, about half of U.S. adults have literacy
skills that are inadequate to meet the demands of today’s health system.
Health-care systems could address this problem through processes and poli-

298 HEALTH LITERACY
cies that enhance employee awareness of patients’ health literacy skills, and
by delivering information in ways that patients can understand.
A variety of public and private entities have a stake in the health
literacy problem. These include health insurers, employers, and advocacy
groups. Insurers have a stake in the problem because of the high cost of
health care for persons with limited literacy. For example, because limited
literacy skills are so common among the elderly, most of Medicare’s $240
billion annual budget goes to providing care for persons with limited
literacy.
Employers, especially those that employ large numbers of underedu-
cated service and production workers, also have a stake in health literacy.
Employers pay the high cost of their employee’s health insurance benefits,
and their businesses lose productivity due to higher rates of illness among
employees with limited literacy.
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Sample Material from

Selected Assessments of
Literacy and Health Literacy
T
his appendix presents background and sample items from some of
the measures that have been discussed in this report. For more
information about the development and use of these measures, please
see Chapter 2.
CONTENTS
Rapid Estimate of Adult Literacy in Medicine 302
Excerpts from the Test of Functional Health Literacy in Adults 304
Excerpts from the National Adult Literacy Survey 308
301

302 HEALTH LITERACY
RAPID ESTIMATE OF ADULT LITERACY IN

MEDICINE (REALM)©
TABLE C-1 REALM

Patient Name/ Date of Reading
Subject # ________________________ Birth ___________ Level __________________
Date _________ Clinic __________ Examiner __________ Grade

Completed _____________
List 1 List 2 List 3
Fat Fatigue Allergic

Flu Pelvic Menstrual
Pill Jaundice Testicle
Dose Infection Colitis
Eye Exercise Emergency
Stress Behavior Medication
Smear Prescription Occupation
Nerves Notify Sexually
Germs Gallbladder Alcoholism
Meals Calories Irritation
Disease Depression Constipation
Cancer Miscarriage Gonorrhea
Caffeine Pregnancy Inflammatory
Attack Arthritis Diabetes
Kidney Nutrition Hepatitis
Hormones Menopause Antibiotics
Herpes Appendix Diagnosis
Seizure Abnormal Potassium
Bowel Syphilis Anemia
Asthma Hemorrhoids Obesity
Rectal Nausea Osteoporosis
Incest Directed Impetigo
SCORE
List 1 __________________
List 2 __________________
List 3 __________________
Raw Score _____________

APPENDIX C 303
Directions:
1. Give the patient a laminated copy of the REALM and score an-
swers on an unlaminated copy that is attached to a clipboard. Hold the
clipboard at an angle so that the patient is not distracted by your scoring
procedure. Say:
“I want to hear you read as many words as you can from this list. Begin
with the first word on List 1 and read aloud. When you come to a word
you cannot read, do the best you can or say “blank” and go on to the next
word.”
2. If the patient takes more than five seconds on a word, say “blank”
and point to the next word, if necessary, to move the patient along. If the
patient begins to miss every word, have him or her pronounce only known
words.
3. Count as an error any word not attempted or mispronounced.
Score by marking a plus (+) after each correct word, a check (✓) after each
mispronounced word, and a minus (–) after words not attempted. Count as
correct any self-corrected word.
4. Count the number of correct words for each list and record the
numbers in the “SCORE’ box. Total the numbers and match the total score
with its grade equivalent in the table below (Table C-2).
TABLE C-2 Scores and Grade Equivalents for the REALM

GRADE EQUIVALENT
Raw Score Grade Range
0–18 3rd Grade and below

• Will not be able to read most low literacy materials; will need repeated
oral instructions, materials composed primarily of illustrations, or audio
or videotapes
19–44 4th to 6th Grade
• Will need low literacy materials; may not be able to read prescription
labels
45–60 7th to 8th Grade
• Will struggle with most patient education materials; will not be
offended by low literacy materials
61–66 High School
• Will be able to read most patient education materials
Excerpts taken from: Davis TC, Crouch MA, Long SW. 1993. Rapid Estimate of Adult
Literacy in Medicine: A Shortened Screening Instrument. Louisiana State University. Re-
printed with permission.

304 HEALTH LITERACY
EXCERPTS FROM THE TEST OF FUNCTIONAL

HEALTH LITERACY IN ADULTS
Numeracy
The numeracy section of the TOFHLA measures the patient’s ability to
understand and act on numerical directions given by a health-care provider
or pharmacist. The test items reproduce real-life situations in receiving,
following, and paying for medication plans. The numeracy section uses a
series of prompts to which the patient responds. These prompts consist of
prescription vials, an appointment slip, a chart describing eligibility for
financial aid, and an example of results from a medical test. The patient is
handed the prompt for each question, the administrator reads each ques-
tion, and the responses are recorded.
Sample Items
At the beginning of this section, the following introduction is read:
“These are directions you or someone else might be given at the hospital.
Please read each direction to yourself. Then I will ask you some questions
about what it means.” For the first few questions in this section the patient
is given Prompt 1, a prescription bottle that has the label shown in Figure
C-1 below taped to it.
GARFIELD IM 16 Apr 93
FF941858 Dr. Lubin, Michael
PENICILLIN VK
250MG 40/0
Take one tablet by mouth four
times a day 02 (4 of 40)
FIGURE C-1 Prompt 1 for TOFHLA. Prescription label that should taped onto
an actual prescription bottle that can be handed to the patient to read.
Questions for Prompt 1:

If you take your first tablet at 7:00 am, when should you take the next
one?
And the next one after that?
What about the last one for the day, when should you take that one?

APPENDIX C 305
At the end of the numeracy section, the patient is given Prompt 10, a
laminated card with information shown in Figure C-2 below.
You can get care at no cost if after deductions your monthly

income and other resources are less than:
$581 for a family of one $1,196 for a family of four

$786 for a family of two $1,401 for a family of five
$991 for a family of three $1,606 for a family of six.
FIGURE C-2 Prompt 10 for TOFHLA. Laminated card with financial informa-
tion about clinic services.
Question for Prompt 10:

Let’s say that after deductions, your monthly income and other resources
are $1,129. And, let’s say you have 3 children. Would you have to pay for
your care at that clinic?
Reading Comprehension
The reading comprehension section of the TOFHLA measures a
patient’s ability to read passages using real materials from the health-care
setting using a modified Cloze procedure. Passages included come from
instructions for preparation for an upper GI series, the patient rights and
responsibilities section of a Medicaid application form, and standard hospi-
tal informed consent language.
Sample Items
At the beginning of the reading comprehension section of the TOFHLA,
the following instructions are read:
Here are some other medical instructions that you or anybody might see
around the hospital. These instructions are in sentences that have some of
the words missing. Where a word is missing, a blank line is drawn, and 4
possible words that could go in the blank appear just below it. I want you
to figure out which of those 4 words should go in the blank, which word
makes the sentence make sense. When you think you know which one it
is, circle the letter in front of that word, and go on to the next one. When
you finish the page, turn the page, and keep going until you finish all the
pages.
The reading comprehension section consists of three passages; one of these
passages is shown on the next page.

306 HEALTH LITERACY
PASSAGE B: Medicaid Rights and Responsibilities

I agree to give correct information to __________ if I can receive Medicaid.
a. hair
b. salt
c. see
d. ache
I _________ to provide the county information to ___________ any

a. agree a. hide
b. probe b. risk
c. send c. discharge
d. gain d. prove
statements given in this ________________ and hereby give permission to

a. emphysema
b. application
c. gallbladder
d. relationship
the _______________ to get such proof. I _______________ that for

a. inflammation a. investigate
b. religion b. entertain
c. iron c. understand
d. county d. establish
Medicaid I must report any ______________ in my circumstances

a. changes
b. hormones
c. antacids
d. charges
within __________ (10) days of becoming ___________ of the change.

a. three a. award
b. one b. aware
c. five c. away
d. ten d. await
I understand __________ if I DO NOT like the ____________ made on my

a. thus a. marital
b. this b. occupation
c. that c. adult
d. than d. decision
case, I have the ____________ to a fair hearing. I can _____________ a

a. bright a. request
b. left b. refuse
c. wrong c. fail
d. right d. mend

APPENDIX C 307
hearing by writing or _____________ the county where I applied.

a. counting
b. reading
c. calling
d. smelling
If you __________ AFDC for any family ____________, you will have to
a. wash a. member,
b. want b. history,
c. cover c. weight,
d. tape d. seatbelt,
_____________ a different application form. _____________, we will use

a. relax a. Since,
b. break b. Whether,
c. inhale c. However,
d. sign d. Because,
the __________ on this form to determine your _______________.

a. lung a. hypoglycemia.
b. date b. eligibility.
c. meal c. osteoporosis.
d. pelvic d. schizophrenia.
Excerpts taken from: Nurss JR, Parker RM, Williams MV, Baker DW. 2001. Test of
Functional Health Literacy in Adults. Available from Peppercorn Books and Press, Inc. Re-
printed with permission.

308 HEALTH LITERACY
EXCERPTS FROM THE NATIONAL ADULT

LITERACY SURVEY
Prose Literacy and Sample Items
Prose refers to any written text such as editorials, news stories, poems,
and fiction, and can be broken down into two types: expository prose and
narrative prose. Expository prose consists of printed information that de-
fines, describes, or informs, such as newspaper stories or written instruc-
tions. Narrative prose tells a story. Prose varies in its length, density, and
structure (e.g., use of section headings or topic sentences for paragraphs).
Prose literacy tasks include locating all the information requested, integrat-
ing information from various parts of a passage of text, and writing new
information related to the text.
Prose Literacy Levels

Adults included in level 1 were those who could succeed at level 1 tasks,
but not at level 2 tasks, as well as those who could not succeed at level 1
tasks and those who were not literate enough in English to take the test at
all. Adults in levels 2 through 4 were able to succeed at tasks at their
proficiency level, but not at tasks for the next more difficult level. Adults in
level 5 are able to succeed at level 5 tasks.
Prose Level 1. Level 1 prose literacy tasks required a person to read a

short passage of text and locate a single piece of information that is identi-
cal to or synonymous with the information given in the question. If plau-
sible but incorrect information was present in the text, it tended not to be
located near the correct information.
Sample Prose Item (Level 1): Swimmer Article: Locate Fact with No
Distractor
Task: Use the article “Swimmer completes Manhattan marathon” (See Fig-
ure C-3) to answer the following question.
Underline the sentence that tells what Ms. Chanin ate during the swim.
The answer is correct if respondent underlines, circles, or puts a mark
next to the sentence beginning A Spokesman for the Swimmer, or under-
lines, circles, or puts a mark next to any part of the sentence that just lists
the foods.
This level 1 task asks respondents to read a newspaper article about a
marathon swimmer and to underline the sentence that tells what she ate

APPENDIX C 309
FIGURE C-3 Article “Swimmer completes Manhattan marathon” used in NALS.
during a swim. Only one reference to food is contained in the passage, and
it does not use the word “ate.” Rather, the article says the swimmer “kept
up her strength with banana and honey sandwiches, hot chocolate, lots of
water and granola bars.” The reader must match the word “ate” in the
directive with the only reference to foods in the article.
Prose Level 2. Prose literacy tasks at level 2 required a person to locate a

single piece of information in the text, compare and contrast easily identifi-
able information based on criteria provided in the question, or integrate
two or more pieces of information, when distractors were present or when
low level inferences were required.
Sample Prose Item (Level 2): Swimmer Article: Locate Fact with
Distractor
Task: Use the article “Swimmer completes Manhattan marathon” (see Fig-
ure C-3 above) to answer the following question.
At what age did Chanin begin swimming competitively?
Acceptable responses are underlining or circling age or the sentence con-
taining the age in the article.

310 HEALTH LITERACY
This level 2 task requires the reader to locate information in the text.
The reader is asked to identify the age at which the marathon swimmer
began to swim competitively. The article first provides the swimmer’s cur-
rent age of 23, which is a plausible but incorrect answer. The correct
information, age 15, is found toward the end of the article.
Prose Level 3. Prose literacy tasks at level 3 required a person to match

literal or synonymous information in the text with that requested in the
question, to integrate multiple pieces of information from dense or lengthy
text, or to generate a response based on information that could be easily
identified in the text. Distracting information was present, but was not
located near the correct information.
Sample Prose Item (Level 3): Discrimination Article

Task: Refer to the article below (Figure C-4) to answer this question.
List two things that Chen became involved in or has done to help resolve
conflicts due to discrimination.
The answer is correct if the respondent lists any two of the following:
• worked for EEO Commission or was litigator on behalf of plain-

tiffs who experienced discrimination
• served on Philadelphia Commission on Human Relations or
worked with community leaders (to resolve racial and ethnic tensions)
• contributed free legal counsel (to a variety of activist groups)
• called for a meeting of community leaders to help resolve conflict
over desecration of Korean street signs
• involved in Hispanic, Jewish, and black issues
• involved in Ethnic Affairs Committee of Anti-Defamation League
of B’nai B’rith or just B’nai B’rith
This level 3 item requires the reader to read a magazine article about an
Asian-American woman and to provide two facts that support an inference
made from the text. The question directs the reader to identify what Ida
Chen did to help resolve conflicts due to discrimination.
Prose Level 4. Prose literacy tasks at level 4 required a person to search

through text and match multiple features, and to integrate or synthesize
multiple pieces of information from complex or lengthy passages. More
complex inferences were required, and conditional information had to be
taken into consideration for these tasks.

APPENDIX C 311
FIGURE C-4 Discrimination article used in NALS.

312 HEALTH LITERACY
Sample Prose Item (Level 4): Korean Jet Article

Task: This question directs the reader to state what argument Tom Wicker
is making in the editorial below (Figure C-5).
In this level 4 item, the answer is correct if the argument is identified
and respondents make a statement about the author’s main point. Answers
were marked incorrect if the argument was not identified, respondents
wrote what the article was about, or listed evidence without stating the
argument. Answers that used the prompt as a basis for personal digression
were also marked incorrect. The item is reflective of other tasks at this level
of difficulty, which often have repetitive statements that are elaborated in
the text so that the propositions supporting the theme, though repetitive,
are widely separated in the text.
Prose Level 5. Prose literacy tasks at level 5 required a person to search

through text and match multiple features contained in dense text with a
number of plausible distractors, to compare and contrast complex informa-
tion, or to generate new information making high-level inferences or using
specialized background knowledge.
Document Literacy and Sample Items

Documents are short forms or graphically displayed information found
in everyday life, including job applications, payroll forms, transportation
schedules, maps, tables, and graphs. Document literacy tasks included lo-
cating a particular intersection on a street map, using a schedule to choose
the appropriate bus, or entering information on an application form.
Document Literacy Levels

Document Level 1. Document literacy tasks at level 1 required a person to

locate information based on a literal match to the question or to enter
information from personal knowledge into a document. Little, if any, dis-
tracting information was present.

APPENDIX C 313
FIGURE C-5 Korean jet article used in NALS.

314 HEALTH LITERACY
FIGURE C-6 Job application used in NALS.
Sample Document Item (Level 1): Job Application (Figure C-6)

Task:
The answer is correct if the respondent satisfactorily completes the
form portion (birth date, age, sex, height, weight, health, grade).
In this task, readers were asked to complete a section of a job applica-
tion by providing several pieces of information. Here, respondents had to
conduct a series of one-feature matches.
Sample Document Item (Level 1): Net Pay

Task: Here is a wage and tax statement that comes with a paycheck (Figure
C-7). What is the current net pay?
The correct answer to this item is: 459.88.
This level 1 question asks, “what is the current net pay?” Since the term
appears only once on the pay stub and there is only one number in the
column, this task requires only a one-feature match and receives a difficulty
value that lies within the level 1 range on the document scale.
Document Level 2. Document literacy tasks at level 2 required the reader to

match a piece of information either when several distractors were present

APPENDIX C 315
FIGURE C-7 Wage and tax statement used in NALS.
or when low-level inferences were required. Tasks at this level also asked
the reader to cycle through information in a document or to integrate
information from various parts of a document.
Sample Level 2 Item

Task: You are a marketing manager for a small manufacturing firm. This
graph (Figure C-8) shows your company’s sales over the last three years.
Given the seasonal pattern shown on the graph, predict the sales for Spring
1985 (in thousands) by putting an “x” on the graph.
The answer is correct if the respondent puts an “x” or other mark on
the graph at any point above the point for Winter, 1984, in the area under
1985.
This level 2 task asks respondents to study a line graph showing a
company’s seasonal sales over a three-year period, then predict the level of
sales for the following year, based on the seasonal trends shown in the
graph. It requires readers to integrate information from different parts of
the document by looking for similarities or differences.

integrate multiple pieces of information from one or more documents.
Other tasks asked readers to cycle through complex tables or graphs and
locate particular features. The displays contained information that was
irrelevant or inappropriate to the task.

316 HEALTH LITERACY
FIGURE C-8 Sales graph used in NALS.
Sample Level 3 Item: Energy Chart (Figure C-9)

Question: In the year 2000, which energy source is predicted to supply a
larger percentage of total power than it did in 1971?
A Coal
B Petroleum
C Natural Gas
D Nuclear Power
E Hydropower
F I don’t know
The correct answer to this item is: D. Nuclear power.
This level 3 task directs the reader to a stacked bar graph depicting
estimated power consumption by source for four different years. The reader
is asked to select an energy source that will provide a larger percentage of
total power in the year 2000 than it did in 1971. To succeed on this task,
the reader must first identify the correct years and then compare each of the
five pairs of energy sources given.

perform multiple-feature matches, cycle through documents, and integrate

APPENDIX C 317
FIGURE C-9 Energy chart used in NALS.

SOURCE: U.S. Department of Interior United States Energy through the year 2000.
BTU: Quantity of heat required to raise temperature of one pound of water one
degree Fahrenheit.
Copyright 1973 Congressional Quarterly Inc.
information, all of which required high-level inferences. Many of these

tasks required readers to provide numerous responses but did not designate
how many responses were needed. Conditional information was also present
in the tasks at this level and had to be taken into account by the reader.
Sample Level 4 Item: Bus Schedule (Figure C-10)

On Saturday afternoon, if you miss the 2:35 bus leaving Hancock and
Buena Ventura going to Flintridge and Academy, how long will you have to
wait for the next bus?
The correct answer to this item is: C. Until 3:35 p.m.
This level 4 task combines many of the variables that contribute to
difficulty in level 5. These include multiple feature matching, complex dis-

318 HEALTH LITERACY
FIGURE C-10 Bus schedule used in NALS.
plays involving nested information, numerous distracters, and conditional

information that must be taken into account in order to arrive at a correct
response. Using the bus schedule, readers are asked to select the time of the
next bus on a Saturday afternoon, if they miss the 2:35 bus leaving Hancock
and Buena Ventura going to Flintridge and Academy. Several departure
times are given, from which respondents must choose the correct one.

search through complex displays that contained multiple distractors, to
make high-level text-based inferences, and to use specialized knowledge.
Tasks required readers to integrate information, compare and contrast data
points, and to summarize the results.
Quantitative Literacy and Sample Items

Quantitative information may be displayed visually in graphs or charts
or in numerical form using whole numbers, fractions, decimals, percent-

APPENDIX C 319
ages, or time units (hours and minutes). These quantities appeared in both
prose and document form. Quantitative literacy refers to locating quanti-
ties, integrating information from various parts of a document, determining
the necessary arithmetic operation, and performing that operation. Quanti-
tative literacy tasks included balancing a checkbook, completing an order
form, and determining the amount of interest paid on a loan.
Quantitative Literacy Levels

Quantitative Level 1. Quantitative literacy tasks at level 1 required a person

to perform single, relatively simple arithmetic operations, such as addition,
when the question included the numbers to be used and the arithmetic
operation to be performed.
Sample Quantitative Item (Level 1): Adding Deposits (Figure C-11)

Task: You wish to use the automatic teller machine at your bank to make a
deposit. Figure the total amount of the two checks being deposited. Enter
the amount on the form in the space next to TOTAL.
The correct answer to this item is $632.19.
This level 1 item is the least demanding task on the quantitative scale. It
requires the reader to total two numbers on a bank deposit slip. In this task,
both the numbers and the arithmetic operation are judged to be easily
identified and the operation involves the simple addition of two decimal
numbers that are set up in column format.

to locate numbers by matching the required information with that given,
infer the necessary arithmetic operation, or perform an arithmetic opera-
tion when the tasks specified the numbers and the operation to be per-
formed. The quantities could be easily located in the text, and the operation
could be determined from the format of the material.

to locate numbers by matching the required information with that given,
infer the necessary arithmetic operation and perform arithmetic operations

320 HEALTH LITERACY
FIGURE C-11 Bank deposit slip used in NALS.
on two or more numbers, or to solve a problem, when the numbers must be

located in the text or document. The required operation(s) could be deter-
mined from the arithmetic-relation terms used in the question.

to perform two or more sequential arithmetic operations or a single arith-
metic operation, when the quantities could be found in different displays,
or when the operations had to be inferred from semantic information given
or drawn from prior knowledge.
Sample Quantitative Item (Level 4): Unit Price (Figure C-12)

Task: Estimate the cost per ounce of the creamy peanut butter. Write your
estimate on the line provided.
The correct answer to this item is: Any figure from 9 (.09) to 10 (.10).
This level 4 item task requires the reader to select from two unit price
labels to estimate the cost per ounce of creamy peanut butter. To perform
this task successfully, readers may have to draw some information from
prior knowledge.
Level 4 tasks require either two sequential operations or the application

APPENDIX C 321
FIGURE C-12 Peanut butter label used in NALS.
of a single higher level operation, such as multiplication. In this example,

readers are shown a menu and are required to compute the cost of a
specified meal and use multiplication to determine a ten percent tip.

to perform multiple arithmetic operations sequentially, when the features
of the problem had to be extracted from text; or when background knowl-
edge was required to determine the quantities or operations needed.
Sample Quantitative Item (Level 5): Interest Charges (Figure C-13)

Task: Use the ad for Home Equity Loans to answer this question.
You need to borrow $10,000. Explain to the interviewer how you
would compute the total amount of interest charges you would pay under
this loan plan. Please tell the interviewer when you are ready to begin.
The answer is correct if the speaker explains the two basic steps in
computing the total interest charges, i.e., the monthly payment ($156.77)
times the number of payments (120) equals the total loan payment; the

322 HEALTH LITERACY
total loan payment minus the amount of the loan ($10,000) equals the total
interest charges.
One of the most difficult tasks on the quantitative scale, this item
requires readers to look at an advertisement for a home equity loan and
then, using the information given, explain how they would calculate the
total amount of the interest charges associated with the loan.
FIGURE C-13 Home equity loan advertisement used in NALS.
Excerpts taken from: National Center for Education and Statistics, U.S. Department of
Education. Defining Literacy and Sample Items. [Online]. Available: http://nces.ed.gov/naal/
defining/defining.asp [accessed: October, 2003].

Committee and Staff Biographies
David A. Kindig, M.D., Ph.D. (Chair), is Emeritus Professor of Population

Health Sciences and Emeritus Vice Chancellor for Health Sciences at the
University of Wisconsin-Madison. He is also Co-director of the Wisconsin
Public Health and Health Policy Institute. He served as Vice Chancellor for
Health Sciences at the University of Wisconsin-Madison (1980–1985), Di-
rector of Montefiore Hospital and Medical Center (1976–1980), Deputy
Director of the Bureau of Health Manpower, U.S. Department of Health,
Education and Welfare (1976), and medical director of the National Health
Service Corps (1971–1973). He served as Chair of the federal Council of
Graduate Medical Education (1995–1997), President of the Association for
Health Services Research (1997–1998), ProPAC Commissioner (1991–
1994) and Senior Advisor to Donna Shalala, Secretary of Health and Hu-
man Services (1993–1995). In 1996 he was elected to the Institute of Medi-
cine (IOM), National Academy of Sciences. Dr. Kindig received a B.A. from
Carleton College and M.D. and Ph.D. degrees from the University of Chi-
cago School of Medicine. His research interests include population health
status, supply and distribution of health professionals, equity in health
services, and physician and nurse executives. His current work derives from
his 1997 book “Purchasing Population Health: Paying for Results.”
Dyanne D. Affonso, Ph.D., R.N., F.A.A.N., is Dean of the Faculty of Nurs-

ing at the University of Toronto. She is a leading educator who has advo-
cated for curricula reforms in the health sciences to produce culturally
competent health professionals. She is a researcher in women’s health is-
323

324 HEALTH LITERACY
sues, community-based interventions, and reducing health disparities

through studies on testing community prenatal care programs for ethnically
diverse women, post-partum depression screening among culturally diverse
women, and school-based violence prevention program for ethnically di-
verse children. She designed several DHSS-HRSA special projects to cus-
tomize health-care services to immigrant and low-income families across
the United States. She has participated in several National Institutes of
Health (NIH) initiatives and review groups addressing the health needs of
culturally diverse populations, specifically the National Cancer Institute’s
(NCI’s) Special Population Networks and NCMH’s Centers for Reducing
Health Disparities. A member of the IOM since 1994, she received her
Ph.D. in clinical psychology from the University of Arizona, a master’s
degree in nursing from the University of Washington, and a bachelor’s
degree in nursing from the University of Hawaii.
Eric H. Chudler, Ph.D., is a Research Associate Professor in the Depart-

ment of Anesthesiology at the University of Washington in Seattle, WA. His
current research interests include how Parkinson’s disease affects the brain,
how the brain processes pain signals, and how the nervous system reacts to
nerve injury. Dr. Chudler creates neuroscience curricula, and provides in-
formation to teachers and students (grades K-12) who want to learn more
about the nervous system. He also created the Neuroscience for Kids
website, funded by the NIH. Dr. Chudler received his M.S. and Ph.D.
degrees from the Department of Psychology at the University of Washing-
ton, and received his post-doctoral training from the NIH. He was also an
Instructor in the Department of Neurosurgery at the Massachusetts Gen-
eral Hospital in Boston.
Marilyn H. Gaston, M.D., is a past Assistant Surgeon General of the United

States and Director of the Bureau of Primary Health Care of the Health
Resources and Services Administration. Her career has focused on improv-
ing the health of poor and minority families through the delivery of quality
primary patient care through the provision of medical education, involve-
ment in clinical research, and the administration of local and federal pro-
grams directed to services to the underserved. Dr. Gaston is internationally
recognized for her leadership in sickle cell disease. Through her work at the
NIH, changes in management of children with this illness have resulted
significantly in decreasing the morbidity and mortality in young children.
Elected to the IOM in 1996, she frequently speaks on improving access to
quality care, elimination of health disparities, African-American women’s
health, sickle cell disease, and the health needs of youths.

APPENDIX D 325
Cathy D. Meade, Ph.D., R.N., F.A.A.N., is Professor in the Department of

Interdisciplinary Oncology, Division of Cancer Prevention and Control at
the University of South Florida College of Medicine, and Director of the
Education Program at the H. Lee Moffitt Cancer Center & Research Insti-
tute. She also holds a joint appointment in the College of Nursing. She was
one of the first investigators to conduct studies in the area of patient
understanding identifying the mismatches between patients’ reading levels
and the reading levels of health information. She has extensive experience
in the development of relevant cancer communications and has produced
numerous printed and electronic materials and media for lay and profes-
sional audiences. Practical aspects of this work have been published widely
to help professionals develop easy-to-understand educational materials and
interventions. Her research interests center on crafting culturally, linguisti-
cally, and literacy-appropriate health communications, creating sustained
community-based cancer education, outreach, and screening initiatives for
underserved priority populations, examining understanding of the clinical
trial and informed consent process, and developing innovative cancer edu-
cation and training programs to increase the number of researchers from
underrepresented groups. Dr. Meade has served as a member on NCI’s
work groups on Cancer and Literacy, and Informed Consent in Cancer
Clinical Trials for increasing awareness of the impact of literacy in health
care. Dr. Meade also provides leadership for numerous education and
training initiatives that address the nexus of cancer, culture, and literacy.
Ruth Parker, M.D., is Associate Professor of Medicine, and Associate Di-

rector of Faculty Development for the Division of General Medicine at the
Emory University School of Medicine. Her primary research interests are in
medical education and health services of underserved populations. Dr.
Parker has focused extensively on the health-care issues of underserved
populations, particularly health literacy. She was principal investigator in
the Robert Wood Johnson Literacy in Health Study, and worked with
collaborators to develop the Test of Functional Health Literacy in Adults
(TOFHLA), a measurement tool to quantify patients’ ability to read and
understand health information. She is widely published in health literacy,
and co-edited the complete bibliography of medicine on health literacy for
the National Library of Medicine. She is chair of the American Medical
Association (AMA) Foundation steering committee for the national pro-
gram on health literacy, a member of the ACP Foundation Health Commu-
nication Intiative Committee, and former chair of the AMA expert panel
for the Council of Scientific Affairs.

326 HEALTH LITERACY
Victoria Purcell-Gates, Ph.D., is a Professor of Literacy and Teacher Educa-

tion at Michigan State University, where she teaches courses in literacy
teaching and research. A former middle and high school teacher, Purcell-
Gates had directed literacy centers for children needing help with reading
and writing at both the University of Cincinnati and Harvard University.
She studies literacy acquisition and development in the context of families,
communities, and schools. As part of this, she studies the influence of
culture, class, gender, and SES on literacy development and on access to
literacy learning in schools. She has just concluded a longitudinal experi-
mental study of text genre instruction in second- and third-grade science
classes, sponsored by the National Science Foundation and IERI. Her latest
book (Print Literacy Development), to be issued by Harvard University
Press in 2004, is based on a multiyear study of relationships between adult
literacy instructional factors and change in home literacy practices, spon-
sored by the National Center for the Study of Adult Literacy and Learning.
Her teaching experience has been primarily with children and adults who
have experienced difficulty learning to read and write in school.
Irving Rootman, Ph.D., is Professor and Michael Smith Foundation for

Health Research Distinguished Scholar in the Faculty of Human and Social
Development at the University of Victoria in British Columbia, Canada,
and was Professor of Public Health Sciences and Director of the Centre for
Health Promotion at the University of Toronto. He was Director of the
Health and Welfare Canada Program Resources Division and Chief of
Health Promotion Studies in the Health Promotion Directorate, and Chief
of Epidemiological and Social Research in the Non-Medical Use of Drugs
Directorate. He has acted as Senior Scientist, consultant, and technical
advisor for the World Health Organization (WHO), and chaired the WHO-
EURO Working Group on Health Promotion Evaluation. He has published
widely in the field of health promotion, and co-authored a book entitled
People-Centred Health Promotion. Dr. Rootman serves on the Health Pro-
motion and Disease Prevention Board of the IOM and is a former member
of the Canadian Minister of Health’s Science Advisory Board.
Rima Rudd, Sc.D., is Senior Lecturer on Society, Human Development, and

Health at the Harvard University School of Public Health. She is a public
health educator and her work centers on health communication and on the
design and evaluation of public health community-based programs. She
teaches graduate courses on health literacy, innovative strategies in health
education, and program planning and evaluation. Dr. Rudd’s current re-
search is focused on health disparities and on literacy-related barriers to
health programs, services, and care. She works closely with the adult educa-
tion, public health, and medical sectors. She is a research fellow of the

APPENDIX D 327
National Center for the Study of Adult Learning and Literacy and is Princi-
pal Investigator (PI) for the Health and Adult Literacy studies. Dr. Rudd
also serves as PI for the Literacy in Arthritis Management: A Randomized
Controlled Trial of a Novel Patient Education Intervention with the RB
Brigham Arthritis and Musculoskeletal Diseases Clinical Research Center
and a co-PI on Pathways Linking Education to Health Study with col-
leagues at the Harvard School of Public Health. She worked with Drs.
Kirsch and Yamamoto of the Educational Testing Services (ETS) to develop
a Health Activities and Literacy Scale that provides baseline data for health
literacy assessment and discussed in a forthcoming ETS policy report. Dr.
Rudd authored the action plan for the health literacy objective in Health
People 2010.
Susan C. Scrimshaw, Ph.D., is Dean of the School of Public Health and

Professor of Community Health Sciences and Anthropology at the Univer-
sity of Illinois at Chicago. Dr. Scrimshaw has worked widely with diverse
populations in cross-cultural settings in the fields of medical and applied
anthropology, demography, culture change, and population health. An in-
volved IOM Member, Dr. Scrimshaw has served on the IOM Board on
International Health and the IOM Panel on Cancer Research among Mi-
norities and the Medically Underserved. She is Member of the Task Forces
on Community Preventive Services and on Violence Prevention at the Cen-
ters for Disease Control and Prevention, and Member of the Executive
Council of the Illinois Department of Public Health. Dr. Scrimshaw has
worked extensively with city, state, governmental, national, and United
Nations agencies. She has been honored by the American Anthropological
Association and the Society for Applied Anthropology with the Margaret
Mead Award for outstanding achievement in bringing anthropology to a
wider audience.
William Smith, Ed.D., is Executive Vice President and Senior Social Scien-
tist of Development Program Services at the Academy of Educational De-
velopment (AED). Dr. Smith supervises programs of communication and
marketing for social change, and serves as senior scientist for the develop-
ment of behavior change programs at AED, publishing and speaking to
policy-making audiences around the world. He often acts as consultant to
international organizations including UNICEF and WHO, as well as na-
tional departments of health and the Centers for Disease Control and Pre-
vention. Dr. Smith is recognized as one of the leading specialists in the
application of social marketing to social change, and he is co-founder of the
Institute for Social Marketing. He has designed, supervised, and evaluated
social marketing and communication campaigns on HIV/AIDS prevention
in 22 countries, and infant and maternal health in 35 countries of the
world.

328 HEALTH LITERACY
IOM Staff
Lynn T. Nielsen-Bohlman, Ph.D., is a Senior Program Officer in the Board
on Neuroscience and Behavioral Health. Dr. Nielsen-Bohlman’s research
focused on human distributed cortical networks in working memory and
attention, and their modulation by arousal, aging, cortical and subcortical
degeneration, and cortical lesion. Her studies on the differential involve-
ment of anterior and posterior cortices in working memory provided the
first evidence of a distributed working memory network in humans. Dr.
Nielsen-Bohlman received her Ph.D. in physiology from the University of
California at Davis in 1994. She was a postdoctoral fellow at the University
of California, Berkeley, and the University of California, San Francisco,
Assistant Professor of Psychiatry at Vanderbilt University, and a Psychol-
ogy Department faculty member at Belmont University and the University
of Maryland University College. She is the Study Director for the Commit-
tee on Health Literacy, and has worked in science and education outreach
for two decades.
Allison M. Panzer is a Research Assistant in the Board on Neuroscience and

Behavioral Health, and has worked on studies of the pathophysiology and
prevention of adolescent and adult suicide and how to optimize the public
health response to long-term and short-term mental health consequences of
terrorism. This work has contributed to two IOM reports: Reducing Sui-
cide: A National Imperative and Preparing for the Psychological Conse-
quences of Terrorism: A Public Health Strategy. Allison received her
Bachelor’s Degree from Wesleyan University with coursework in psychol-
ogy, sociology, and neuroscience, and has pursued postgraduate studies
while at the National Academies.
Benjamin N. Hamlin, Research Assistant at IOM, received his bachelors in

Biology from the College of Wooster in 1993 and a degree in health sci-
ences from the University of Akron in 1996. He joined the National Acad-
emies in 2000 as a Research Assistant for the Division on Earth and Life
Studies. His work at IOM has included Testosterone and Aging: Clinical
Research Directions; Review of NASA’s Longitudinal Study of Astronaut
Health; Health Literacy: A Prescription to End Confusion; Improving Medi-
cal Education: Enhancing the Behavioral and Social Science Content in
Medical School Curricula; and NIH Extramural Center Programs: Criteria
for Initiation and Evaluation.
Allison L. Berger is a Project Assistant in the Board on Neuroscience and

Behavioral Health. She is currently working on two IOM studies: Health
Literacy and Introducing Behavioral and Social Sciences into Medical

APPENDIX D 329
School Curricula. Before joining the IOM staff, she enjoyed a 5-year tenure
as an Administrative Assistant for the American Psychological Association
(APA) where she assisted the APA Committee on Psychological Test and
Assessment, Committee on Scientific Awards, and the Committee on Ani-
mal Research and Ethics. She also worked on several funding and grant
programs sponsored by the APA Science Directorate.
Andrew M. Pope, Ph.D., is Director of the Board on Neuroscience and

Behavioral Health, and Director of the Board on Health Sciences Policy at
IOM. With a Ph.D. in physiology and biochemistry, his primary interests
focus on environmental and occupational influences on human health. Dr.
Pope’s previous research activities focused on the neuroendocrine and re-
productive effects of various environmental substances in food-producing
animals. During his tenure at the National Academy of Sciences and since
1989 at IOM, Dr. Pope has directed numerous studies; topics include injury
control, disability prevention, biologic markers, neurotoxicology, indoor
allergens, and the enhancement of environmental and occupational health
content in medical and nursing school curricula. Most recently, Dr. Pope
directed studies on NIH priority-setting processes, organ procurement and
transplantation policy, and the role of science and technology in countering
terrorism.


Index
A Adult education system, 154–157

context of, 154–155
AARP, 119, 292–293 incorporating health content into,
ABEL. See Adult basic education and 156–157
literacy system strategies and opportunities in, 155–157
Aboriginal people, cultural language of, Adult Literacy & Lifeskills Survey (ALL),
114–115 62
Academy for Educational Development, Adult population groups
153 percentage with literacy skills at NALS
Academy of General Dentistry, 193 levels 1, 2, or 3-4, 64
Access to health care and preventive percentage with literacy skills at NALS
services, 179–180 levels 1 or 2, 294
See also Language access Advertising and marketing
Accreditation Council for Continuing FDA involvement in, 194
Medical Education (ACCME), 159 a popular source of health
Accreditation of health systems information, 123–124
Joint Commission on Accreditation of Advocacy organizations, 292
Healthcare Organizations, 14, 16, for African-Americans, 294–295
55, 199, 228 for the elderly, 292–293
National Committee for Quality for Hispanics, 293–294
Assurance, 14, 16, 55, 199–201, prison systems, 296
228, 278 professional associations, 296–297
Accreditation of medical education social service agencies, 296
Accreditation Council for Continuing African-Americans
Medical Education, 159 advocacy organizations for, 294–295
Ad Hoc Committee on Health Literacy, literacy proficiency among, 63
36 National Association for the
Adult Basic Education and Literacy Advancement of Colored People,
(ABEL) system, 10, 154 294–295
331

332 INDEX
National Medical Association, 295 excerpts from the Test of Functional

National Urban League, 295 Health Literacy in Adults, 304–307
Agency for Healthcare Research and Rapid Estimate of Adult Literacy in
Quality (AHRQ), 14–15, 103, 127, Medicine, 302–303
136, 183, 197, 205, 291 sample material from selected, 301–322
Agency for International Development Association of American Colleges and
(AID), 25 Universities, 147
Agency roles, 191–201 Associations of limited health literacy, 6–
AHRQ. See Agency for Healthcare 9, 59–107
Research and Quality associations with health knowledge,
AID. See Agency for International behavior, and outcomes, 82–100
Development financial, 7–8, 100–103
Alaska Natives, literacy proficiency in health knowledge, behavior, and
among, 63 outcomes, 7, 82–100
ALL. See Adult Literacy & Lifeskills Survey Attaining Cultural Competency and
Alzheimer’s Association of Los Angeles, Enriching Health Service Solutions,
135 133
AMA. See American Medical Association Awareness, cultural, 112
American Academy of Neurology, 297
American Association of Family
Physicians Foundation, 26 B
American Cancer Society, 119
American Medical Association (AMA), Background information, 250–254
160, 193 Basic print literacy, 38–39
Bayer Corporation, 146
Ad Hoc Committee on Health
Literacy, 36, 109 Behavior, associations of limited health
American Public Health Association, 160 literacy with, 7, 82–100
Behavioral Health Risk Factor
Americans with Disabilities Act, 184n
America’s health literacy Surveillance System (BHRFSS), 14,
advocacy organizations, 286 53, 55
BHRFSS. See Behavioral Health Risk
employers, 286
governmental and social service Factor Surveillance System
agencies, 286–287 Billie, Alvin, 132
Bolivia, literacy proficiency in, 83
insurers, 286
organizations and systems acting to Bridging Disciplines in the Brain:
improve, 286–287 Behavioral and Clinical Sciences,
224
Approaches to improving health literacy,
127–137 Building Effective AIDS Response
approaches to increasing language initiative, 218
Bureau of Primary Health Care, 197, 219
access, 136–137
collaborative programs, 134–136
community opportunities, 127, 132–133
nongovernmental organizations, 134
C
Asian Health Services, 133 CAHL. See Coalition for Allied Health
“Ask Me 3” program, 160 Leadership
Assessment Framework Matrix, 152 CAHPS. See Consumer Assessment of
Assessment of health literacy, in Health Plans Survey
educational settings, 151–152 Calculating literacy, 45
Assessments of literacy and health literacy California HealthCare Foundation, 26
excerpts from the National Adult California Literacy, Inc., 160
Literacy Survey, 308–322 California Medical Association (CMA), 160

INDEX 333
California Statewide Health Initiative, 160 Civil Rights Act, 184n

Canada, literacy in, 61 Clinician–patient communication, office-
Capacity, individual, 32 based, 271–272
Care delivery, 269 Cloze procedure, 48
Carmona, Richard H., 136 CMA. See California Medical Association
Carstairs Index, of social deprivation, 88– CMS. See Centers for Medicare and
89 Medicaid Services
Case studies. See Vignettes Coalition for Allied Health Leadership
CDC. See Centers for Disease Control and (CAHL), 159
Prevention Collaborative programs, to improve health
Center for Epidemiologic Studies literacy, 134–136
Depression Scale-Short Form, 96–97 College and university health education,
Center for Health Services Research and 147–148
Policy, 200 Combined approaches, to health literacy
Center for Linguistic and Cultural in the health system, 220–221
Competence in Health Care, 114 Comments, from respondents to
Center for Youth Services, 134 surveyors, 227
Centers for Disease Control and Commissioned papers and background
Prevention (CDC), 14–15, 103, information, 250–299
119, 136, 153, 161, 192, 195, 267 approaches to improving health
Health Communication Division, 218 literacy, 250–253
“Programs-That-Work,” 148 federal funding for health literacy over
School Health Policies and Programs a 10-year period, 254
Study 2000, 143 field lessons, 250–253
Task Force on Guidelines for Committee on Comprehensive School
Community Preventative Services, Health Programs in Grades K-12,
127 146
Centers for Medicare & Medicaid Services Committee on Health Literacy, 3, 26–27,
(CMS), 100n, 135, 193–194 243
Centro Latino de Salud, Educación y First Workshop hosted by, 246
Cultura, 133 Second Workshop hosted by, 248
Charlson Comorbidity Index, 90–91 Third Workshop hosted by, 249
Children’s Partnership, 124 Commonwealth fund, 26
Chronic Care Model, 173, 268–271, 274– Communication techniques
275, 279 office-based clinician-patient, 271–272
shaping for patients with limited health personal, 219–220
literacy, 274–277 technology-based, 215–218
Chronic disease care and self- Community-based interventions, published
management, 171–173 studies of, 128–133
chronic disease management program, Community factors
222 effect on chronic disease outcomes,
model for improvement of, 279 274
Chronic disease outcomes opportunities to improve health
community and environmental factors, literacy, 127, 132–133
274 Complexity of health information, 122–
effect of limited health literacy on, 123
270–274 Components of literacy, 38
home-based monitoring and clinical Conceptual framework for health literacy,
support, 272–274 32–35
office-based clinician–patient culture and society, 33–34
communication, 271–272 education system, 34–35

334 INDEX
health system, 35 Curricular approaches, to educating health

potential points for intervention in the professionals, 158–159
health literacy framework, 34 Curriculum Linking Science Education
Consumer Assessment of Health Plans and Health Literacy program, 146,
Survey (CAHPS), 98–99, 200 153
Consumer-directed health care, 182–183 Cycling literacy, 44
Context of health systems, 168–201
emerging issues in the health system
context, 171–183 D
health law and health literacy, 183–191
Contexts of health literacy and Data sources and methods, 243–254
opportunities for intervention, 9–12 commissioned papers and background
information, 250–254
culture and society, 9–10, 108
educational systems, 10–11, 142 literature review, 243–244
health systems, 11–12, 167 public workshops, 244–249
study committee, 243
Continuing education approaches, to
educating health professionals, Definition of health literacy, 31–37
159–160 conceptual framework for health
literacy, 32–35
Costs. See Health expenditures
Council of Chief State School Officers, scope of health literacy, 36–37
State Collaborative on Assessment Definition of literacy, 37–40
basic print literacy, 38–39
and Student Standards, 152
Council of State Governments, 198, 251 components of literacy, 38
CRISP database, 195, 254 functionality of all literacy, 39–40
literacy for different types of text, 39
Crossing the Quality Chasm: A New
Health System for the 21st Demographic associations, with limited
Century, 12, 26, 177, 228 literacy, 62–65
Department of Cancer Control and
Cultural competence, 112–113
cultural awareness, 112 Population Science, Portfolio
cultural encounter, 112 Management Application software,
254
cultural knowledge, 112
cultural skill, 112 Disease registries, 269
Cultural languages, traditional, 114–115 Document literacy, and sample items from
the National Adult Literacy Survey,
Culture
dissociation of culture, meaning, and 312–319
health literacy, measures for, 118–
119
language and meaning, in the context
E
of health literacy, 115–118 “Ecology” of health service organizations,
mass culture, 119–126 169
meaning and language, in the context Economic factors, and health, 20–21
of health literacy, 115–118 Education for health professionals, 157–
traditional culture, 110–119 160
Culture and society, 9–10, 108–141 continuing education approaches, 159–
health literacy in, 33–34 160
mass culture, 119–126 curricular approaches, 158–159
opportunities for intervention in, 9–10, Educational materials
108 grade-level measures of, 47
opportunities to improve health tailored to health literacy in the health
literacy, 126–137 system, 221–224
traditional culture, 110–119

INDEX 335
Educational Resources Information Center from the Test of Functional Health

(ERIC), 68, 127, 244 Literacy in Adults, 304–307
Educational systems, 10–11, 142–166 Executive Order No. 13166, “Improving
adult education system, 154–157 Access to Services for Persons with
education for health professionals, Limited English Proficiency, August
157–160 2000,” 114n
health literacy in, 34–35 Expenditures. See Health expenditures
K-12 and university education systems, Experiential identity, 111
143–154 Extent and associations of limited health
opportunities for intervention in, 10– literacy, 6–9, 59–107
11, 142 the associations of limited health
recommendations, 161 literacy, 81
strategies for health literacy the epidemiology of limited health
instruction, 149–151 literacy, 65–81
Elderly people, advocacy organizations literacy in America, 60–65
for, 292–293 mock-up prescription medication
Emerging issues in the health system instructions in Bahasa Malaysia,
context, 171–183 the written language of Malaysia,
access to health care and preventive 60
services, 179–180 recommendation, 103
chronic disease care and self-
management, 171–173
consumer-directed health care, 182– F
183
Family and friends, a popular source of
health expenditures, 181–182
limitations on provider time, 180–181 health information, 125
patient–provider communication, 173– FDA. See Food and Drug Administration
Federal government, 191–198
175
patient safety and health-care quality, Agency for Healthcare Research and
176–179 Quality, 197
Centers for Disease Control and
Employers, 290–292
Encounters, cultural, 112 Prevention, 195
England, literacy in, 61 Centers for Medicare and Medicaid
Services, 193–194
Environmental factors, effect on chronic
disease outcomes, 274 Department of Veterans Affairs, 197–
Epidemiology of limited health literacy, 198
Food and Drug Administration, 194–195
65–81
association of limited health literacy, funding for health literacy over a 10-
81–103 year period, 254
Health Resources and Services
and health literacy skills among
various populations, 70–81 Administration, 196–197
studies of limited health literacy, 67– National Institutes of Health, 195–196
Office of the Secretary, Office of
69, 80
ERIC. See Educational Resources Disease Prevention and Health
Information Center Promotion, 192–193
Field lessons, 250–253
Evidence-based approaches, to improving
health literacy, 126–127 Financial associations, of limited health
Excerpts literacy, 7–8, 100–103
First Workshop, hosted by the Committee
from the National Adult Literacy
Survey, 308–322 on Health Literacy, 246
Flesch-Kincaid Reading Grade Level, 47

336 INDEX
Flesch Scale Analysis, 201 Health, social and economic factors in,
Florida/Caribbean AIDS Education and 20–21
Training Center, 218 Health Assessment Questionnaire, 88–89
Food and Drug Administration (FDA), Health care
192, 194–195 and informed consent in research,
advertising, 194 187–190
labeling, 194 predicted spending on, 262
outreach, 194 quality of, 176–179
Formulating literacy, 45 Health Care Financing Administration
Foundation for Accountability, 183 (HCFA), 100, 291
Foundation for Informed Medical See also Centers for Medicare &
Decision Making, 217 Medicaid Services
Friends, a popular source of health Health-care settings, interventions in,
information, 125 206–213
Fry Readability Scale, 47, 201 Health Communication Division (CDC),
Functional literacy 218
functionality of all literacy, 39–40 Health content, incorporating into adult
measures of, 49–50 education programs, 156–157
Health contexts, literacy skill demands of,
41, 43
G Health Education Assessment Project,
152
Gallup Organization polls, 121, 146 Health education programs
sources of health information reported K-12, 143–146
in, 121
opportunities for, 148–149
Gathering Place, 132 Health expenditures, 181–182
Generating literacy, 45 “Health Framework for California’s
Georgia Academy of Family Physicians,
Public Schools, Kindergarten
297 through Grade Twelve,” 153
Geriatric Depression Scale, 84–85, 88–89 Health Information National Trends
GEs. See Grade Equivalents
Survey (HINTS), 121
Governmental and agency roles, 191–201 Health information sources, 123–126
roles of regulatory agencies, 199–201 advertising and marketing, 123–124
roles of state governments, 198–199
family and friends, 125
roles of the federal government, 191– the Internet, 125–126
198 news media, 123
Grade Equivalents (GEs), 46
Health information use, 120–126
for the REALM, 303 complexity of materials, 122–123
Grade-level measures of literacy, 45–47, selected findings from Sex Matters, 122
50
sources of health information reported
grade-level ability for individual in a Gallup Poll, 121
readers, 46–47 Health Insurance Portability and
grade-level measures of materials, 47
Accountability Act of 1996, 192
Gunning Fog index, 50 Health Interview Survey (HIS), 53
“Health is Strength” Project, 133
Health knowledge, associations of limited
H health literacy with, 7, 82–100
Hablamos Juntos, 114–115 Health law and health literacy, 183–191
Harvard School of Public Health, 158 doctrine of informed consent, 186–191
HCFA. See Health Care Financing governmental and agency roles, 191–201
Administration standard of reasonable care, 184–186

INDEX 337
Health literacy, 4–6, 31–58 Health service organizations, ecology of,

definition of, 31–37 169
framework for, 33 Health systems, 11–12, 167–239
measures used in health literacy context of, 168–201
research, 43–51 emerging issues in, 171–183
needs and opportunities, 51–55 health literacy in, 35
new field of inquiry and practice, 20 Joint Commission on Accreditation of
opportunities to improve, 126–137 Healthcare Organzations, 14, 16,
as a public concern, 25–26 55, 199, 228
sample material from selected National Committee for Quality
assessments of, 301–322 Assurance, 14, 16, 55, 199–201,
Health Literacy, Let Your Patients 228, 278
Understand, 160 navigating, 172
Health literacy approaches in the health opportunities in, 11–12, 167, 201–227
system, 204–225 Healthcare processes, rules for
combined approaches, 220–221 redesigning, 178
and in-sample prediction of total costs, Healthy People 2010 program, 4, 25, 31,
263 36–37, 125, 149, 192–193
partnerships, 224–225 “Healthy Reading Kits,” 153
personal communication and Helling v. Carey, 186
education, 219–220 HHS. See U.S. Department of Health and
provision of simplified/more attractive Human Services
written materials, 214–215 Hidding v. Williams, 190
tailored materials, 221–224 HINTS. See Health Information National
technology-based communication Trends Survey
techniques, 215–218 HIS. See Health Interview Survey
Health Literacy Coalition, 160 Hispanics
Health Literacy Educational Kit, 160 advocacy organizations for, 293–294
Health literacy framework, potential cultural language of, 116–118
points for intervention in, 5, 34 literacy proficiency among, 63
Health literacy instruction, strategies for, Mexican American Legal Defense and
149–151 Educational Fund, 293
Health literacy measures, 50–51 National Council of La Raza, 293
Health literacy-related activities, frequency National Hispanic Medical
of doing, 203 Association, 293–294
Health literacy skills HIV/AIDS Bureau, 197, 218
among various populations, Home-based monitoring and clinical
epidemiology of, 70–81 support, effect on chronic disease
health-related associations of, 84–99 outcomes, 272–274
Health-literate America, vision for, 12–14, Ho’oponopono process, 175
240–242 Hospital Anxiety and Depression Scale,
Health on the Net Foundation Code of 88–89
Conduct, 273 Howard, David H., 8, 101, 256–266
Health Professions Network, 159 HRSA. See Health Resources and Services
Health-related associations, of health Administration
literacy skills, 84–99
Health Resources and Services
Administration (HRSA), 14–15, I
103, 136, 161, 196–197, 218–219,
226 IALS. See International Adult Literacy
Bureau of Primary Health Care, 219 Surveys

338 INDEX
IDL. See Instrument for Diagnosis of Institutional Review Boards, 16

Reading/Instrumento Para Instrument for Diagnosis of Reading/
Diagnostical Lecturas Instrumento Para Diagnostical
“Improving Access to Services for Persons Lecturas (IDL), 47, 65, 78–79,
with Limited English Proficiency, 100
August 2000,” 114n Insurers, 285–290
“Improving Chronic Disease Care for Medicaid, 288–290
Populations with Limited Health Medicare, 285, 287–288
Literacy,” 171n, 267–284 Tricare, 285, 290
Chronic Care Model, 268–270 Integrating literacy, 44
effect of limited health literacy on Interagency Education Research Initiative,
chronic disease outcomes, 270–274 15, 150–151, 161
a framework based on health literacy International Adult Literacy Surveys
and related research, 271 (IALS), 6, 45, 49, 52, 61
measuring progress, 277–278 International Reading Association, 50
shaping the chronic care model for Internet, 119
patients with limited health a popular source of health
literacy, 274–277 information, 125–126
Improving Diabetes Efforts across Intervention in the health literacy
Language and Literacy project, 218 framework
Improving health literacy opportunities for, 9–12
collaborative programs, 134–136 potential points for, 5, 34
combined approaches, 220–221 samples of published studies of, 206–
community-based interventions, 128– 213
133 IOM. See Institute of Medicine
community opportunities, 127, 132–133 Iowa Medical Society, 297
lessons from the field, 250–253 Ireland, literacy in, 61
nongovernmental organizations, 134
promising approaches to, 127–137
Incollingo v. Ewing, 185 J
Increasing language access, approaches to,
136–137 JCAHO. See Joint Commission on
Indian Health Service, 15, 136 Accreditation of Healthcare
Organizations
Individual capacity, 32
Inflexxion® Incorporated, 153 Joint Commission on Accreditation of
Informed consent, 186–191 Healthcare Organizations
(JCAHO), 14, 16, 55, 199, 228
consent form, for participation in
smoking cessation study, 216 Joint Committee on National Health
difference between actual readability Standards, 11, 36, 144
Journal of the American Medical
and target readability of
documents, 188–189 Association, 119
in health care and research, 187–190
legal precedents, 190–191
texts provided by institutional review
K
boards at U.S. medical schools, 188 K-12 education, 143–147
Institute for Healthcare Advancement, 134 health education programs,
Institute for Policy Innovation, 124 143–146
Institute of Medicine (IOM), 3, 9, 12–13, literacy education, 147
20–21, 25, 101, 111, 115, 117, science education, 146
168–169, 197, 224, 240, 244 Kellogg Foundation, 26
Committee on Comprehensive School Knowledge, cultural, 112
Health Programs in Grades K-12,
146

INDEX 339
L living in a society with high demands

for, 21–25
Labeling, FDA involvement in, 194 sample material from selected
Language assessments of, 301–322
and meaning, in the context of health, Literacy education, K-12, 147
115–118 Literacy in America, 60–65
patient perspectives and, 117–118 demographic associations with limited
traditional, 113–114 literacy, 62–65
Language access, approaches to extent and associations of, 60–65
increasing, 136–137 Literacy surveys, 43–45
“Language Access: Helping Non-English calculating, 45
Speakers Navigate Health and cycling, 44
Human Services,” excerpt from formulating, 45
introduction to, 136 generating, 45
Legal issues integrating, 44
doctrine of informed consent, 186–191 locating, 44
governmental and agency roles, 191– Literature review, 243–244
201 Locating literacy, 44
standard of reasonable care, 184–186
Legal precedents, 190–191
LEP. See Limited English proficiency M
Limitations of existing measures of health
literacy, 49–51 Maintenance-of-Effort (MOE) funds, 135
functional literacy measures, 49–50 Managed Care Consumer Assistance
grade-level scores, 50 Program (MCCAP), 134
health literacy measures, 50–51 Managed care contracts, state Medicaid,
Limitations on provider time, 180–181 200–201
Limited English proficiency (LEP), 113– Marketing health information, 123–124
114 Mass culture, 119–126
Limited health literacy, 6–9, 59–107 advertising and marketing, 123–124
associations of, 7, 81–103 family and friends, 125
financial associations of, 7–8 Internet, 125–126
studies of, 67–69, 80 news media, 123
Limited health literacy’s effect on chronic ways people obtain and use health
disease outcomes, 270–274 information, 120–126
community and environmental factors, Materials
274 grade-level measures of, 47
home-based monitoring and clinical tailored to health literacy in the health
support, 272–274 system, 221–224
office-based clinician-patient Maternal and Child Health Bureau, 197
communication, 271–272 MBS. See Medicare Beneficiaries Survey
Limited literacy, demographic associations MCCAP. See Managed Care Consumer
with, 62–65 Assistance Program
Literacy MDI. See Metered dose inhaler technique
components of, 38 Meaning and language, in the context of
for different types of text, 39 health, 115–118
examples of skills needed for health, Measures used in health literacy research,
42 43–51
in health contexts, 41–43 grade-level measures of literacy, 45–47
literacy skill demands of health limitations of existing measures, 49–51
contexts, 41, 43 literacy surveys, 43–45
measures of health literacy, 47–49

340 INDEX
“Media Smart Youth”, 153 energy chart used in, 317

Medicaid, 15, 48, 65, 135, 274, 288–290 excerpts from, 308–322
Arizona enrollees, 100 home equity loan advertisement used
state managed care contracts, 200–201 in, 322
Medicaid Health Plan Employer Data and job application used in, 314
Information Set, 277 Korean jet article used in, 313
Medical Expenditure Panel Survey Level 1, 8, 10, 45, 61–65, 100, 102,
(MEPS), 14, 53, 55 120, 123
Medicare, 15–16, 83, 102, 228, 274, 285, Level 2, 8, 10, 45, 61–64, 102, 120
287–288 Level 3, 10, 45, 120
federal spending for, 285, 288 Level 4, 45, 61
numbers of enrollees in, 287 Level 5, 61, 123
predicted expenditures on, 289 peanut butter label used in, 321
Medicare Beneficiaries Survey (MBS), 14, prose literacy and sample items, 308–
53, 55 312
Medline, 68, 127, 244 quantitative literacy and sample items,
MEPS. See Medical Expenditure Panel 319–322
Survey sales graph used in, 316
Metered dose inhaler (MDI) technique, wage and tax statement used in, 315
98–99 National Assessment of Adult Literacy
Metlife Foundation, 26 (NAAL), 14, 49, 53, 55, 62
Mexican American Legal Defense and National Association for the Advancement
Educational Fund, 293 of Colored People (NAACP), 294–
Migrant Health Centers, 219 295
Mini-Mental State Examination (MMSE), National Cancer Institute (NCI), 26, 121,
84–85 153, 215, 254
MMSE. See Mini-Mental State National Center for Education Statistics,
Examination 193, 292
MOE. See Maintenance-of-Effort funds National Center for Health Promotion
Molina Healthcare, 134 and Disease Prevention (NCP), 197
Morocco, literacy proficiency in, 83 National Center for Research Resources,
153
National Center for the Study of Adult
N Learning and Literacy (NCSALL),
155–156
NAACP. See National Association for the National Committee for Quality
Advancement of Colored People
Assurance (NCQA), 14, 16, 55,
NAAL. See National Assessment of Adult 199–201, 228, 278
Literacy National Conference of State Legislatures’
NALS. See National Adult Literacy Survey
Children’s Policy Initiative, 136
National Adult Literacy Survey (NALS), National Council of La Raza, 293
6, 25, 44, 49–50, 52–53, 60–67, National Council on the Aging, 160
80, 100, 102, 120, 154, 274, 288,
National Health Education Standards:
297 Achieving Health Literacy (NHES),
article “Swimmer completes 11, 15, 143–145, 152, 161
Manhattan marathon” used in, 309
National Health Objectives, 148
bank deposit slip used in, 320 National Hispanic Medical Association,
bus schedule used in, 318 293–294
discrimination article used in, 311
National Immunization Program, 195
document literacy and sample items, National Institute for Literacy (NIFL),
312–319 155, 251

INDEX 341
National Institute for Occupational Safety NICHD. See National Institute of Child
and Health, 195 Health and Human Development
National Institute of Child Health and NIFL. See National Institute for Literacy
Human Development (NICHD), NIH. See National Institutes of Health
15, 147, 161, 196 No Child Left Behind legislation, 147
National Institute of Environmental Nongovernmental organizations,
Health Sciences, 196 opportunities to improve health
National Institutes of Health (NIH), 14, literacy, 134
16, 52, 55, 103, 119, 195–196, Northwest AIDS Education and Training
229 Center, 218
Department of Cancer Control and NRC. See National Research Council
Population Science, 254 Numeracy, sample items from the Test of
grant funding over the 1997–2002 Functional Health Literacy in
period, 196 Adults, 304–305
National Library of Medicine, 4, 31, 119
National Literacy Act of 1991, 43
National Medical Association, 112n, 295 O
National Network of Health Career
Office-based clinician–patient
Programs in Two Year Colleges,
159 communication, effect on chronic
National Research Council (NRC), 147 disease outcomes, 271–272
Office of Civil Rights, 135
National Science Foundation, 15, 150–
151, 161 National Standards to Protect the
National Science Teachers Association, Privacy of Personal Health
Information, 192
146, 150
National Standards to Protect the Privacy Office of Disease Prevention and Health
of Personal Health Information, Promotion (OPHP), 192–193
Office of Minority Health, 14, 136
192
National Survey on Health Literacy Center for Linguistic and Cultural
Initiatives, 198 Competence in Health Care, 114
Office of National Drug Control Policy,
National Urban League, 295
National Youth Anti-Drug Media National Youth Anti-Drug Media
Campaign, 124 Campaign, 124
Office of the Secretary, Office of Disease
Native Americans
cultural language of, 114–115 Prevention and Health Promotion,
literacy proficiency among, 63 192–193
Office of Vocational and Adult Education,
Native Hawaiians, understanding of
healing, 175 15, 154–155
NCI. See National Cancer Institute OPHP. See Office of Disease Prevention
and Health Promotion
NCP. See National Center for Health
Promotion and Disease Prevention Opportunities to improve health literacy
NCQA. See National Committee for in health systems, 201–227
approaches to health literacy in the
Quality Assurance
NCSALL. See National Center for the health system, 204–225
Study of Adult Learning and evidence-based approaches, 126–127
other promising approaches, 127–137
Literacy
News media, a popular source of health overview of current efforts, 202–204
information, 123 recommendations, 228–229
summary of approaches, 226–227
NHES. See National Health Education
Standards: Achieving Health Organization for Economic Co-operation
Literacy and Development, 61

342 INDEX
Organizations, acting to improve Prison systems, as advocacy organizations,

America’s health literacy, 286–287 296
Outcomes, associations of limited health Private sector, national totals for enrollees
literacy with, 7, 82–100 and cost of hospitalization and
Outreach, FDA involvement in, 194 physician service health plans for
“Outside the Clinician–Patient United States, 2000, 291
Relationship—A Call to Action for Professional associations, as advocacy
Health Literacy,” 63n, 285–299 organizations, 296–297
advocacy organizations, 292 Program for Appropriate Technology in
employers, 290–292 Health, 134
insurers, 285–290 “Programs-That-Work,” 148
OVID web gateway, 68 Progress, measuring, 277–278
Project Toolbox, description of, 223
ProLiteracy America, 296
P Promoting Health: Intervention Strategies
from Social and Behavioral
Pacific Islanders, literacy proficiency Research, 111
among, 63 Prose literacy, and sample items from the
Pakistan, literacy proficiency in, 83, 100
National Adult Literacy Survey,
Partnership for Clear Health 308–312
Communication, 160 Prudential Medicare HMO, 256
Partnerships, for health literacy in the
PsychInfo, 127, 244
health system, 224–225 PT Tool, 223–224
Patient-centered approach, 179 Public concern, health literacy as, 25–26
Patient Navigator Program, 220
Public workshops, 244–249
Patient perspectives, and language, 117– Published studies of community-based
118 interventions, examples of, 128–
Patient–provider communication, 173–175
133
Patient safety and health-care quality,
176–179
Peabody Individual Achievement Test- Q
Revised, 48
People’s finding and using health Quality Chasm Report. See Crossing the
information, 120–126 Quality Chasm: A New Health
Percentiles, 46 System for the 21st Century
Pfizer Corporation, 26, 160, 214 Quantitative literacy, and sample items
Pictograms for patient education, from the National Adult Literacy
examples of, 215 Survey, 319–322
“Plain Talk,” 134
Popular sources of health information,
123–126 R
advertising and marketing, 123–124
family and friends, 125 Race, and literacy proficiency, 63
Rapid Estimate of Adult Literacy in
the Internet, 125–126
news media, 123 Medicine (REALM)©, 47–51, 66–
Portfolio Management Application 68, 70–73, 76–79, 81–89, 92–95,
98–100, 195, 219, 302–303
software, 254
Prescription medication instructions, in scores and grade equivalents for, 303
Bahasa Malaysia, mock-up of, 60 Readability, of informed consent
documents, 189
Priority Areas for National Action in
Quality Improvement, 13, 26, 168– Reading comprehension, sample items
169, 240 from the Test of Functional Health
Literacy in Adults, 305–307

INDEX 343
REALM. See Rapid Estimate of Adult Self-management educational activities,

Literacy in Medicine 269
Reasonable care, standard of, 184–186 Sex Matters, 121–122
Recommendations, 14–16 selected findings about the way people
for development of conceptual obtain and use health information,
frameworks, 137 122
for educational systems, 161 SF-12. See Short Form-12 Health Survey
for extent and associations of limited Shaw, George Bernard, 267
health literacy, 103 “Shima Yazhi” lay health program, 132
for health literacy, 55 Short Form-12 Health Survey (SF-12), 84–
for opportunities in health systems, 85, 90–91, 259–261
228–229 Short Test of Functional Health Literacy
Redesigning healthcare processes, rules in Adults (S-TOFHLA), 49, 66, 68–
for, 178 69, 72–73, 76–79, 81, 83–85, 88–
Regulatory agencies, 199–201 89, 96–99, 101, 219, 256–258, 272
Joint Commission on Accreditation of Simplified Measure of Gobbledygook
Healthcare Organizations, 199 (SMOG), 47, 201
National Committee for Quality Simplified/more attractive written
Assurance, 199–201 materials, to improve health
“Relationship Between Health Literacy literacy in the health system, 214–
and Medical Costs,” 101n, 256– 215
266 Skill
data description, 256–259 cultural, 112
discussion, 263–264 needed for health, 42
results, 261–263 Slosson Oral Reading Test-Revised, 48
statistical analysis, 260–261 SMOG. See Simplified Measure of
Robert Wood Johnson Foundation, 26, Gobbledygook
116 Social factors, and health, 20–21
Roles Social service agencies, as advocacy
of the federal government, 191–198 organizations, 296
of regulatory agencies, 199–201 Society
of state governments, 198–199 culture and, 9–10, 108–141
Roosevelt, Eleanor, 1 health literacy framework, 5, 34
opportunities for intervention in, 9–10,
108
S Sociological Abstracts, 68, 127, 244
Sources of health information, 123–126
S-TOFHLA. See Short Test of Functional advertising and marketing, 123–124
Health Literacy in Adults family and friends, 125
Scandinavian countries, literacy in, 61
the Internet, 125–126
SCASS. See State Collaborative on news media, 123
Assessment and Student Standards Speaking of Health, 20, 112, 217, 221
Schillinger, Dean, 267–284
Standard of reasonable care, 184–186
SCHIP. See State Children’s Health Standard scores, 46
Insurance Program Stanines, 46
School Health Education Profiles Study, 145
State Children’s Health Insurance Program
School Health Policies and Programs (SCHIP), 135
Study 2000, 143 State Collaborative on Assessment and
Science education, K-12, 146
Student Standards (SCASS), 152
Scores, for the REALM, 303 Assessment Framework Matrix, 152
Second Workshop, hosted by the Health Education Assessment Project,
Committee on Health Literacy, 248
152

344 INDEX
State Medicaid managed care contracts, See also Short Test of Functional
200–201 Health Literacy in Adults
State Officials Guide to Health Literacy, TEXT study, 150–151
The, 152, 198 Third Workshop, hosted by the
Strategies and opportunities, in the adult Committee on Health Literacy, 249
education system, 155–157 To Err Is Human: Building a Safer Health
Strategies and opportunities in K-12 and System, 25, 173, 176
university systems, 148–154 TOFHLA. See Test of Functional Health
assessment of health literacy in Literacy in Adults
educational settings, 151–152 Traditional culture, 110–119
examples of current approaches, 152– cultural languages, 114–115
154 language, 113–114
opportunities for health education language and meaning in the context
programs, 148–149 of health, 115–118
strategies for health literacy measures able to dissociate culture,
instruction, 149–151 meaning, and health literacy, 118–
Substance Abuse and Mental Health 119
Services Administration, 15, 136 Tricare, 285, 290
Survey of Income and Program
Participation, 100
Surveys U
representatives of the study sample,
257 Unequal Treatment, 136
respondents to survey, comments from, University health education, 147–148
University of Colorado Medical School, 158
227
University of Virginia (UVA) School of
Medicine, 158–159
T U.S. Census, 108
U.S. Department of Defense, 14–15, 103
TANF. See Temporary Assistance for U.S. Department of Education, 15, 154–
Needy Families 155, 161
Target readability, of informed consent National Center for Education
documents, 189 Statistics, 193
Task Force on Guidelines for Community Office of Vocational and Adult
Preventative Services, 127, 267 Education, 15, 154–155
Technology-based communication U.S. Department of Health and Human
techniques Services (HHS), 2, 14, 16, 20, 25,
examples of ongoing approaches using, 55, 103, 119, 149, 181, 193, 228
218 National Standards for Culturally and
and health literacy in the health Linguistically Appropriate Services
system, 215–218 in Health Care, 109
Temporary Assistance for Needy Families Office for Civil Rights, 135
(TANF), 135 Office of the Actuary, 181n
Test of Functional Health Literacy in Task Force on Community Preventive
Adults (TOFHLA), 8, 47–51, 68– Services, 267
71, 74–87, 90–95, 98–99, 101 U.S. Department of Labor, survey by, 44
abbreviated version, 74–75 U.S. Department of Veterans Affairs (VA),
excerpts from, 304–307 197–198
numeracy, sample items, 304–305 National Center for Health Promotion
prompts for, 304–305 and Disease Prevention, 197
reading comprehension, sample items, U.S. Pharmacopeial Convention, Inc.
305–307 (USP), 215

INDEX 345
U.S. Surgeon General, 13, 142, 240–241 W

Use of health information, 120–126
complexity of materials, 122–123 Wagner, Ed, 269
popular sources of health information, Web-based survey, response to, 251
123–126 Weiss, Barry D., 285–299
selected findings from Sex Matters, What to Do for Health, 134
122 WHO. See World Health Organization
sources of health information reported “Who’s in the Driver’s Seat? Increasing
in a Gallup Poll, 121 Consumer Involvement in Health
USP. See U.S. Pharmacopeial Convention, Care,” 183
Inc. Wide Range Achievement Test-Revised
UVA. See University of Virginia (WRAT-R), 47–48, 72–73, 123
Women’s Health Initiative, 43
Workforce Investment Act, 154
V Workshops, hosted by the Committee on
Health Literacy, 246–249
VA. See U.S. Department of Veterans World Bank, 83
Affairs World Health Organization (WHO), 25,
Veterans Administration, 14–15, 49, 103 145
Vignettes, 1, 3, 9, 19, 22, 31, 40, 67, 101, WRAT-R. See Wide Range Achievement
108, 115–116, 167–168, 175, 177, Test-Revised
190, 227, 240 Written materials, simplified/more
Virginia Medical Society, 297 attractive, 214–215
Visual medicine schedule (VMS), 223
VMS. See Visual medicine schedule
Y
Young Adult Literacy Survey, 44


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http://www.nap.edu/catalog/10883.

Health Literacy: A Prescription to End Confusion

Lynn Nielsen-Bohlman, Allison M. Panzer, David A.

This book plus thousands more are available at http://www.nap.edu.

Committee on Health Literacy

Board on Neuroscience and Behavioral Health

Lynn Nielsen-Bohlman, Allison M. Panzer, David A. Kindig, Editors

Copyright © National Academy of Sciences. All rights reserved.

THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, NW • Washington, DC 20001

Library of Congress Cataloging-in-Publication Data

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“Knowing is not enough; we must apply.

Adviser to the Nation to Improve Health

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The Institute of Medicine was established in 1970 by the National Academy of

Copyright © National Academy of Sciences. All rights reserved.

COMMITTEE ON HEALTH LITERACY

Board on Neuroscience and Behavioral Health Liaisons

Board on Health Promotion and Disease Prevention Liaison

IOM Board on Neuroscience and Behavioral Health Staff

Copyright © National Academy of Sciences. All rights reserved.

Copyright © National Academy of Sciences. All rights reserved.

Independent Report Reviewers

Moon Chen Jr., University of California, Davis School of Medicine

Although the reviewers listed above have provided many constructive

Copyright © National Academy of Sciences. All rights reserved.

viii INDEPENDENT REPORT REVIEWERS

Copyright © National Academy of Sciences. All rights reserved.

Copyright © National Academy of Sciences. All rights reserved.

of Health; Heng L. Foong, Pacific Asian Language Services for Health;

Copyright © National Academy of Sciences. All rights reserved.

Copyright © National Academy of Sciences. All rights reserved.

cultural variation in our multicultural society, by technological complexity

Harvey V. Fineberg, M.D., Ph.D.

Copyright © National Academy of Sciences. All rights reserved.

• It will become widely appreciated that 90 million adults with lim-

Copyright © National Academy of Sciences. All rights reserved.

reduce costs, and to reduce disparities cannot succeed without simulta-

Chairing this committee was such a privilege and a challenge. We each

David A. Kindig, M.D., Ph.D.

Copyright © National Academy of Sciences. All rights reserved.

2 WHAT IS HEALTH LITERACY? 31

3 THE EXTENT AND ASSOCIATIONS OF LIMITED

Copyright © National Academy of Sciences. All rights reserved.

4 CULTURE AND SOCIETY 108

5 EDUCATIONAL SYSTEMS 142

6 HEALTH SYSTEMS 167

7 VISION FOR A HEALTH-LITERATE AMERICA 240

A Data Sources and Methods 243

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Tables, Figures, and Boxes

3-1 Percentage of Adult Population Groups with Literacy Skills at

4-1 Examples of Published Studies of Community-Based

6-1 Examples of Informed Consent Text Provided by Institutional

A-1 Summary of Respondents and Non-Respondents to Survey, 252

B-1 Representativeness of the Study Sample, 257

Copyright © National Academy of Sciences. All rights reserved.

xviii TABLES, FIGURES, AND BOXES