The Health Literacy of

America’s Adults

Results From the 2003

National Assessment 

of Adult Literacy 

U.S. Department of Education

NCES 2006–483

The Health Literacy of

America’s Adults

Results From the 2003

National Assessment 

of Adult Literacy 

September 2006

Mark Kutner

Elizabeth Greenberg

Ying Jin

Christine Paulsen

American Institutes 

for Research

Sheida White

Project Officer

National Center for 

Education Statistics

U.S. Department of Education

NCES 2006–483
U.S. Department of Education

Margaret Spellings

Secretary

Institute of Education Sciences

Grover J. Whitehurst

Director

National Center for Education Statistics

Mark Schneider

Commissioner

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Suggested Citation

Kutner, M., Greenberg, E., Jin, Y., and Paulsen, C. (2006). The Health Literacy of America’s Adults: Results From the 2003 National

Assessment of Adult Literacy (NCES 2006–483). U.S. Department of Education. Washington, DC: National Center for Education

Statistics.

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Sheida White

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sheida.white@ed.gov
Executive Summary

The 2003 National Assessment of Adult

Literacy (NAAL) assessed the English literacy of adults in the United States. Included

in the assessment were items designed to measure

the health literacy of America’s adults. The assessment was administered to more than 19,000 adults

(ages 16 and older) in households or prisons. Unlike

indirect measures of literacy, which rely on selfreports and other subjective evaluations, the assessment measured literacy directly through tasks completed by adults.

The health literacy scale and health literacy tasks

were guided by the definition of health literacy used

by the Institute of Medicine and Healthy People

2010 (a set of national disease prevention and health

promotion objectives led by the U.S. Department of

Health and Human Services).This definition states

that health literacy is:

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

and Institute of Medicine 2004)

These health literacy tasks represent a range of literacy activities that adults are likely to face in their

daily lives. Health literacy is important for all adults.

Adults may read an article in a magazine or a pamphlet in their doctor’s office about preventive health

practices; they may need to fill a prescription, select 

iii

Literacy Levels

Demographic Characteristics

and Health Literacy

Overall Health, Health

Insurance Coverage, and

Sources of Information About

Health Issues
and buy an over-the-counter medication, or understand health insurance forms. Parents must manage

their children’s health care, including getting them

immunized, taking them for physicals, and having

their illnesses treated. Adult children are often faced

with the responsibility of managing their own parents’ health care. Older adults must make decisions

about Medicare supplementary insurance and prescription drug benefits. Adults without medical

insurance may need to determine whether they, their

children, or their parents qualify for any public programs. Adults living in older houses and apartments

may need to make decisions about the dangers of

lead paint or asbestos. All these activities require, or

are facilitated by, the ability to read and understand

written and printed information.

The health tasks for the 2003 assessment were developed to fit into the NAAL’s prose, document, or

quantitative scales but were distinguished from the

other tasks on those scales by their health content.

■ The prose literacy scale measured the knowledge and skills needed to search, comprehend,

and use information from texts that were

organized in sentences or paragraphs.

■ The document literacy scale measured the

knowledge and skills needed to search, comprehend, and use information from noncontinuous

texts in various formats.

■ The quantitative scale measured the knowledge

and skills needed to identify and perform computations using numbers embedded in printed

materials.

The NAAL health tasks included on the assessment

were distributed across three domains of health and

health care information and services: clinical, prevention, and navigation of the health system.

This report describes how health literacy varies

across the population and where adults with different

levels of health literacy obtain information about

health issues.The analyses in this report examine differences related to literacy that are based on selfreported background characteristics among groups

in 2003. This report discusses only findings that are

statistically significant at the .05 level.

Literacy Levels

The National Research Council’s Board on Testing

and Assessment (BOTA) Committee on Performance

Levels for Adult Literacy recommended a set of performance levels for the prose, document, and quantitative scales.The Committee on Performance Levels

for Adult Literacy recommended that new literacy

levels be established for the 2003 assessment instead of

using the same reporting levels used for the 1992

National Adult Literacy Survey (Hauser et al. 2005).

Differences between the 1992 and 2003 levels are discussed by the Committee. Drawing on the committee’s recommendations, the U.S. Department of

Education decided to report the assessment results by

using four literacy levels for each scale: Below Basic,

Basic, Intermediate, and Proficient.

The health literacy tasks were analyzed together and

were used to create a health literacy scale. Each

health literacy task was also classified as a prose, document, or quantitative task and was included on one

of those scales.

The BOTA Committee did not recommend performance levels for the health scale. Because every

health literacy task was included on the prose, document, or quantitative scale in addition to the health

scale, it was mapped to a performance level (Below

Basic, Basic, Intermediate, or Proficient) on one of those

scales.Tasks were mapped to each scale at the point on

the scale where an adult would have a 67 percent

iv

The Health Literacy of America’s Adults
probability of doing the task correctly. Cut-points for

the performance levels on the health scale were set so

that each task was classified into the same category on

the health scale as on the other scale (prose,document,

or quantitative) with which the task was associated.

Demographic Characteristics and Health

Literacy

■ The majority of adults (53 percent) had

Intermediate health literacy. An additional

12 percent of adults had Proficient health literacy.Among the remaining adults, 22 percent had

Basic health literacy, and 14 percent had Below

Basic health literacy.

■ Women had higher average health literacy than

men; 16 percent of men had Below Basic health

literacy compared with 12 percent of women.

■ White and Asian/Pacific Islander adults had

higher average health literacy than Black,

Hispanic, American Indian/Alaska Native, and

Multiracial adults. Hispanic adults had lower

average health literacy than adults in any other

racial/ethnic group.

■ Adults who spoke only English before starting

school had higher average health literacy than

adults who spoke other languages alone or

other languages and English.

■ Adults who were ages 65 and older had lower

average health literacy than adults in younger

age groups. The percentage of adults in the 65

and older age group who had Intermediate and

Proficient health literacy was lower than the comparable percentage of adults in other age groups.

■ Starting with adults who had graduated from

high school or obtained a GED, average health

literacy increased with each higher level of educational attainment. Some 49 percent of adults

who had never attended or did not complete

high school had Below Basic health literacy,

compared with 15 percent of adults who ended

their education with a high school diploma and

3 percent of adults with a bachelor’s degree.

■ Adults living below the poverty level had lower

average health literacy than adults living above

the poverty threshold.

Overall Health, Health Insurance Coverage,

and Sources of Information About Health

Issues

■ At every increasing level of self-reported overall health, adults had higher average health literacy than adults in the next lower level.

■ Adults who received health insurance coverage

through their employer or a family member’s

employer or through the military or who privately purchased health insurance had higher

average health literacy than adults who

received Medicare or Medicaid and adults who

had no health insurance coverage. Among

adults who received Medicare or Medicaid,

27 percent and 30 percent, respectively, had

Below Basic health literacy.

■ A lower percentage of adults with Below Basic

health literacy than adults with Basic,

Intermediate, or Proficient health literacy got

information about health issues from any written sources, including newspapers, magazines,

books or brochures, and the Internet. A higher

percentage of adults with Below Basic and Basic

health literacy than adults with Intermediate and

Proficient health literacy received a lot of information about health issues from radio and television.With each increasing level of health literacy, a higher percentage of adults got information about health issues from family members, friends, or coworkers.

v

Executive Summary

Acknowledgments 

The National Assessment of Adult Literacy

(NAAL) is a complex project whose successful completion is due to the work of

countless individuals from many organizations.We,

at the American Institutes for Research (AIR),

especially want to thank the staff at the National

Center for Education Statistics (NCES) who have

supported the project. Sheida White, the NAAL

project officer, has provided substantive guidance

and direction to all aspects of the assessment. Her

intellectual contributions are reflected throughout

the assessment, analyses, and report. Andrew

Kolstad, the project’s senior technical advisor and

project officer of the 1992 National Adult Literacy

Survey, provided both technical guidance and an

institutional memory throughout the project and

helped us reflect on all statistical and technical

issues. Steven Gorman also played a key role in

guiding all aspects of the assessment, especially those

related to the statistical aspects of the assessment.

Peggy Carr, NCES Associate Commissioner for

Assessment,provided the project and team members

with ongoing support, recommendations, and

encouragement.We are very grateful for her leadership.William Tirre and Arnold Goldstein of NCES

played invaluable roles in reviewing the report and

guiding it through the review process. Their 

efforts are very much appreciated. We also thank

Marilyn Seastrom, NCES Chief Statistician,

and members of the NCES/Education Statistics

vii
Services Institute(ESSI) Technical Review Team,

Kevin Bromer, LaTisha Jones, Alison Slade, Aparna

Sundaram, and Jed Tank, who reviewed the report and

made many suggestions that have improved the final

product. Other government reviewers who provided

thoughtful comments are Tom Snyder and John Wirt,

from NCES,and Cheryl Keenan,Director,Division of

Adult Education and Literacy in the Office of

Vocational and Adult Education (OVAE),and Ricardo

Hernandez of OVAE. We also want to thank Jaleh

Soroui of the ESSI for her ongoing substantive contributions to the NAAL.Young Chun, Linda Shafer, and

Alan Vanneman of National Assessment of Educational

Progress (NAEP)-ESSI reviewed the report and 

provided important comments and suggestions.

Cynthia Baur, Office of Disease Prevention and

Health Promotion, Office of Public Health and

Science, Office of the Secretary of the Department

of Health and Human Services, played a pivotal role

in conceptualizing, planning, designing, and reporting on the health literacy component of NAAL.The

NAAL health literacy component is based on her

intellectual contributions and perseverance. Ron

Pugsley, former Director of the Division of Adult

Education and Literacy in the Office of Vocational

and Adult Education, played a key role in the early

planning stages of the health literacy report. Dan

Sherman from AIR also provided invaluable guidance to the health literacy analyses and report.

Our colleagues at Westat, Inc., planned, developed,

and implemented the complex sampling and weighting necessary for the successful completion of the

assessment. Westat also planned and carried out all

phases of the data collection, and was responsible for

training and managing a group of 400 field data collection staff.This study could not have been successful without the outstanding work of the Westat project director, Martha Berlin, and the Westat team,

including Michelle Amsbary, Leyla Mohadjer, and

Jacquie Hogan.

Many staff at AIR made substantial contributions to

the health literacy report, often under tight timelines.

Stéphane Baldi and Justin Baer, senior members of

the AIR NAAL team, provided invaluable substantive and technical contributions throughout the

duration of the project. Bridget Boyle and Yungchen Hsu conducted analyses for the authors whenever requested. Rachel Greenberg and Elizabeth

Moore provided ongoing research and technical support in developing the assessment, preparing the data

and text, and shepherding the report through the

revision and review process.

We are especially appreciative of the skills and contributions by Holly Baker, who edited the report

through multiple revisions, and by Heather Block,

who designed and redesigned the report. We are

grateful for their dedication and in awe of their ability to work under often seemingly impossible time

constraints.Also, Janan Musa provided the AIR team

with invaluable guidance and administrative and

logistical support throughout the project.

We also want to acknowledge the essential contributions of three other individuals.Archie Lapointe was

an active member of the AIR team during the early

stages of the NAAL, and the project greatly benefited from his experience and wisdom.Another former

member of the AIR team, Eugene Johnson, who

directed the assessment’s psychometrics and preliminary analysis activities, played an essential role in the

project.We also want to acknowledge the contributions of Richard Venezky, who provided invaluable

guidance, support, and friendship, and whose memory we cherish.

Thousands of adults participated in the assessment.

Their willingness to spend time answering the background questions and assessment items was essential

to ensuring that meaningful data about the literacy of

America’s adults could be obtained.This study would

not have been possible without their participation.

viii

The Health Literacy of America’s Adults
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Literacy Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv

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

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

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

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

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

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

Chapter 1: Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Defining and Measuring Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

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

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

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

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

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

Chapter 2: Demographic Characteristics and Health Literacy. . . . . . . . . . . . . . . 9

Total Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

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

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

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

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

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

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

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

Chapter 3: Overall Health, Health Insurance Coverage, and Sources of

Information About Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

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

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

ix

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

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

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

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

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

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

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

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

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The Health Literacy of America’s Adults
List of Tables

Table Page

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

D3-6. Estimates and standard errors for Figure 3-6. Percentage of adults who got information about health issues from 

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

D3-7. Estimates and standard errors for Figure 3-7. Percentage of adults who got information about health issues from 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E-12. Average health literacy scores of adults who got information about health issues from newspapers, magazines,

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

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

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

E-14. Average health literacy scores of adults who got information about health issues from newspapers, magazines,

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

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

E-16. Average health literacy scores of adults who got information about health issues from newspapers, magazines,

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

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

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

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

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

E-19. Average health literacy scores of adults who got information about health issues from radio and television,

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

E-20. Average health literacy scores of adults who got information about health issues from radio and television,

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

E-21. Average health literacy scores of adults who got information about health issues from radio and television,

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

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

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

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

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

E-24. Average health literacy scores of adults who got information about health issues from family, friends, or coworkers,

by race/ethnicity: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

E-25. Average health literacy scores of adults who got information about health issues from health care professionals,

by race/ethnicity: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
E-26. Average health literacy scores of adults who got information about health issues from family, friends, or coworkers,

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

E-27. Average health literacy scores of adults who got information about health issues from health care professionals,

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

E-28. Average health literacy scores of adults who got information about health issues from family, friends, or coworkers,

by highest educational attainment: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

E-29. Average health literacy scores of adults who got information about health issues from health care professionals,

by highest educational attainment: 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

xiii

Contents
List of Figures

Figure Page

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

xiv

The Health Literacy of America’s Adults
Introduction

Understanding the health literacy of America’s

adults is important because so many aspects

of finding health care and health information, and maintaining health, depend on understanding written information. Many reports have suggested

that low health literacy is associated with poor communication between patients and health care

providers and with poor health outcomes, including

increased hospitalization rates, less frequent screening

for diseases such as cancer,and disproportionately high

rates of disease and mortality (Baker et al. 1998;

Berkman et al.2004;Gordon et al.2002;Lindau et al.

2001; Rudd et al. 1999; Williams et al. 2002). Low

health literacy may also be associated with increased

use of emergency rooms for primary care (Baker et

al. 2004). These findings have implications for the

costs of caring for patients with low health literacy.

As the Committee on Health Literacy of the

Institute of Medicine wrote:

Health literacy is of concern to everyone

involved in health promotion and protection,

disease prevention and early screening, health

care maintenance,and policy making.Health literacy skills are needed for dialogue and discussion, reading health information, interpreting

charts, making decisions about participating in

research studies, using medical tools for personal

or family health care—such as a peak flow meter

or thermometer—calculating timing or dosage

of medicine,or voting on health or environment

issues. (Institute of Medicine 2004, p. 31)

1

Defining and Measuring

Literacy 

Interpreting Literacy Results

Conducting the Survey

Interpretation of Results

Cautions in Interpretation

Organization of the Report

CHAPTER ONE

1
Health literacy is a new component of the 2003

National Assessment of Adult Literacy (NAAL).

NAAL assessed the English literacy of adults (ages 16

and older) in the United States.The assessment was

administered to more than 19,000 adults (ages 16 and

older) in households or prisons.

This report presents the initial findings on health literacy from the assessment.Analyses presented in this

report, including those in appendix E, are intended

to provide a summary of the relationship between

health literacy and background characteristics of

adults, preventive health practices, and sources of

health information used by adults.

Defining and Measuring Literacy 

Defining Literacy

Unlike indirect measures of literacy—which rely on

self-reports and other subjective evaluations of literacy and education—the 2003 adult literacy assessment measured literacy directly by tasks representing

a range of literacy activities that adults are likely to

face in their daily lives.

The literacy tasks in the assessment were drawn from

actual texts and documents, which were either used

in their original format or reproduced in the assessment booklets. Each question appeared before the

materials needed to answer it, thus encouraging

respondents to read with purpose.

Respondents could correctly answer many assessment questions by skimming the text or document

for the information necessary to perform a given literacy task. None of the tasks were multiple choice

tasks with a list of responses provided. Instead,

respondents had to determine and write their

answers to the questions.

The 2003 assessment used the same definition of literacy as the 1992 National Adult Literacy Survey:

Using printed and written information to function in society, to achieve one’s goals, and to

develop one’s knowledge and potential.

This definition acknowledges that literacy goes

beyond simply being able to sound out or recognize

words and understand text. A central feature of the

definition is that literacy is related to achieving an

objective and that adults often read for a purpose.

Measuring Literacy

Three literacy scales—prose literacy, document literacy, and quantitative literacy—were used in the 2003

assessment:

■ Prose literacy. The knowledge and skills needed

to perform prose tasks (i.e., to search, comprehend, and use information from continuous

texts). Prose examples include editorials, news

stories, brochures, and instructional materials.

Prose texts can be further broken down as

expository, narrative, procedural, or persuasive.

■ Document literacy. The knowledge and skills

needed to perform document tasks (i.e., to

search, comprehend, and use information from

noncontinuous texts in various formats).

Document examples include job applications,

payroll forms, transportation schedules, maps,

tables, and drug and food labels.

■ Quantitative literacy. The knowledge and skills

required to perform quantitative tasks (i.e., to

identify and perform computations, either alone

or sequentially, using numbers embedded in

printed materials). Examples include balancing a

checkbook, figuring out a tip, completing an

order form, and determining the amount of

interest on a loan from an advertisement.

2

The Health Literacy of America’s Adults
In addition, the assessment included a health literacy

scale that consisted of 12 prose, 12 document, and 4

quantitative NAAL items.1 The health literacy items

reflect the definition of health literacy as defined by

the Institute of Medicine and Healthy People 2010

(a set of national disease prevention and health promotion objectives led by the U.S. Department of

Health and Human Services):

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

and Institute of Medicine 2004)

Tasks used to measure health literacy were organized

around three domains of health and health care

information and services: clinical, prevention, and navigation of the health care system.The stimulus materials

and the 28 health literacy tasks were designed to

elicit respondents’ skills for locating and understanding health-related information and services and to

represent the three general literacy scales—prose,

document, and quantitative—developed to report

NAAL results.

The materials were selected to be representative of

real-world health-related information, including

insurance information, medicine directions, and preventive care information. The Office of Disease

Prevention and Health Promotion (ODPHP) within

the U.S. Department of Health and Human Services

suggested materials and questions based on input

from other HHS agencies and stakeholders and

experts, and on information from federal health

materials and other health-related assessments.

Of the 28 health literacy tasks, 3 represented the clinical domain, 14 represented the prevention domain,

and 11 items represented the navigation of the health

care system domain. The domains are defined in the

following way:

■ The clinical domain encompasses those activities

associated with the health care provider-patient

interaction, clinical encounters, diagnosis and

treatment of illness, and medication.Tasks from

the clinical domain are filling out a patient

information form for an office visit, understanding dosing instructions for medication, and following a health care provider’s recommendation

for a diagnostic test.

■ The prevention domain encompasses those activities associated with maintaining and improving

health, preventing disease, intervening early in

emerging health problems, and engaging in selfcare and self-management of illness. Examples

are following guidelines for age-appropriate

preventive health services, identifying signs and

symptoms of health problems that should be

addressed with a health professional, and understanding how eating and exercise habits decrease

risks for developing serious illness.

■ The navigation of the health care system domain

encompasses those activities related to understanding how the health care system works and

individual rights and responsibilities. Examples

are understanding what a health insurance plan

will and will not pay for, determining eligibility for public insurance or assistance programs,

and being able to give informed consent for a

health care service. (HHS, 2003, p. 37)

The NAAL health literacy scale did not include tasks

that did not fit the definitions of prose, document, or

quantitative literacy even if they were consistent with

the definition of health literacy used by Healthy

People 2010. For example, none of the NAAL health

tasks required knowledge of specialized health termi3

Chapter 1: Introduction

1 The NAAL health literacy scale was constructed to have a mean

of 245 and a standard deviation of 55.
nology. The assessment also did not measure the ability to obtain information from nonprint sources,

although questions about the use of all sources of

health information—both written and oral—were

included on the background questionnaire and are

included in this report.

Background Questionnaire

The 2003 National Assessment of Adult Literacy

household background questionnaire was used to

collect data about various demographic and background characteristics of adults. The questionnaire

also included a section of questions specifically related to health status, preventive health practices, health

insurance coverage, and sources of information about

health issues. A summary of the questions that were

used in analyses in this report is presented in appendix B on page 27.

A separate background questionnaire was developed

for adults in prison. Questions about health status

and sources of information about health issues were

included on the prison background questionnaire.

The background questionnaire for prison inmates

did not include questions about health insurance or

about Internet use.

Interpreting Literacy Results

In addition to reporting average literacy scores, another way to report results is by grouping adults with similar scores into a relatively small number of categories,

often referred to as performance levels. Performance

levels are used to identify and characterize the relative

strengths and weaknesses of adults falling within various ranges of literacy ability.Describing the adult population according to such levels allows analysts,policymakers, and others to examine and discuss the typical

performance and capabilities of specified groups within the adult population.2

The National Research Council’s Board on Testing

and Assessment (BOTA) Committee on Performance

Levels for Adult Literacy recommended a new set of 

performance levels for the prose, document, and

quantitative scales for the NAAL, instead of using the

same reporting levels used for the 1992 National

Adult Literacy Survey.3

Drawing on the committee’s recommendations, the

U.S. Department of Education decided to report

NAAL results for the prose, document, and quantitative scales by using four literacy levels for each scale:

Below Basic, Basic, Intermediate, and Proficient.Table 1-1

summarizes the knowledge, skills, and capabilities that

adults needed to demonstrate to be classified into one

of the four levels on the prose, document, and quantitative scales. The items used for the health literacy

scale were also classified as prose, document, and

quantitative items.

The BOTA Committee on Performance Levels for

Adult Literacy was not asked to recommend performance levels for the health scale, because every

health literacy task was included on the prose, document, or quantitative scale. NCES mapped each

health task to the health literacy scale based on their

level of difficulty as prose, document, and quantitative items (see figure 1-1). Each health task was

mapped to the prose, document, or quantitative scale

(depending upon which scale the task fell into) at the

point on the scale (i.e., the scale score) where an

adult with that scale score would have a 67 percent

probability of doing the task correctly. The 67 percent probability convention was used by the BOTA

Committee for the prose, document, and quantitative

scales. That point on the scale was classified as to

whether it fell into the Below Basic, Basic, Intermediate,

or Proficient level.Cut-points for the health scale were

established so that each task was classified into the

The Health Literacy of America’s Adults

4

2 For more information on NAAL performance levels see White

and Dillow (2005).

3 For a description of the process followed by the BOTA

Committee on Performance Levels see Hauser et al. (2005) and

White and Dillow (2005).
Chapter 1: Introduction

same level on the health scale as on the respective

prose, document, or quantitative scale.

A health literacy task that was mapped to the

Proficient level on the prose scale was also mapped to

the Proficient level on the health scale. For example, as

shown in figure 1-1, a task that requires a respondent

to “evaluate information to determine which legal

document is applicable to a specific health care situation” maps to 325 on the health scale, which is at

the Proficient level. The same task maps to 361 on the

prose scale, which is also at the Proficient level.

Similarly, as shown in figure 1-1, a task that requires a

respondent to “determine a healthy weight range for a

person of a specified height, based on a graph that

relates height and weight to body mass index (BMI)”

mapped to 290 on the health scale.This task was also

included on the document scale, where it mapped to

320, or the Intermediate level. The cut-points for the

5

Table 1-1. Overview of the literacy levels

Level and definition Key abilities associated with level

Below Basic indicates no more than the

most simple and concrete literacy skills.

Score ranges for Below Basic:

Prose: 0–209

Document: 0–204

Quantitative: 0–234

Basic indicates skills necessary to perform

simple and everyday literacy activities.

Score ranges for Basic:

Prose: 210–264

Document: 205–249

Quantitative: 235–289

Intermediate indicates skills necessary to

perform moderately challenging literacy

activities.

Score ranges for Intermediate:

Prose: 265–339

Document: 250–334

Quantitative: 290–349

Proficient indicates skills necessary to perform more complex and challenging literacy

activities.

Score ranges for Proficient:

Prose: 340–500

Document: 335–500

Quantitative: 350–500

Adults at the Below Basic level range from being nonliterate in English to having

the abilities listed below:

■ locating easily identifiable information in short, commonplace prose texts

■ locating easily identifiable information and following written instructions in

simple documents (e.g., charts or forms) 

■ locating numbers and using them to perform simple quantitative operations

(primarily addition) when the mathematical information is very concrete and

familiar

■ reading and understanding information in short, commonplace prose texts

■ reading and understanding information in simple documents

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

inferred

■ reading and understanding moderately dense, less commonplace prose texts

as well as summarizing, making simple inferences, determining cause and

effect, and recognizing the author’s purpose 

■ locating information in dense, complex documents and making simple inferences about the information

■ locating less familiar quantitative information and using it to solve problems

when the arithmetic operation is not specified or easily inferred

■ reading lengthy, complex, abstract prose texts as well as synthesizing information and making complex inferences 

■ integrating, synthesizing, and analyzing multiple pieces of information located

in complex documents

■ locating more abstract quantitative information and using it to solve multistep problems when the arithmetic operations are not easily inferred and the

problems are more complex 

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

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

(2005).Key Concepts and Features of the 2003 National Assessment of Adult Literacy (NCES 2006-471). U.S. Department of Education.Washington, DC: National Center for Education Statistics.
6

The Health Literacy of America’s Adults

health scale were set so that the task would also map to

the Intermediate level on the health scale.

As shown in figure 1-1, health tasks that mapped to the

Below Basic level required locating straightforward pieces

of information in short simple texts or documents.

Health tasks that mapped to the Basic level generally

required finding information in texts and documents

that were somewhat longer than those in the Below

Basic level, and the information to be found was usually more complex. For example, a task that mapped to

the Basic level required giving two reasons a person with

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

Proficient 

310–500 

Intermediate 

226–309 

Basic 

185–225 

Below Basic 

0–184 

Health literacy scale 

0 

150 

200 

100 

250 

300 

400 

350 

500 

253 Determine what time a person can take a prescription medication, based on information on the prescription drug label that relates the 

timing of medication to eating. 

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

ages children should receive them. 

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

index (BMI). 

382 Calculate an employee’s share of health insurance costs for a year, using a table that shows how the employee’s monthly cost varies 

depending on income and family size. 

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

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

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

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

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

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

over-the-counter drug label.

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

about the medical condition.

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

written pamphlet. 

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

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

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
7

Chapter 1: Introduction

no symptoms of a specific disease should be tested for

the disease by using information in a pamphlet, while a

task that mapped to the Below Basic level required finding one piece of information–the date–on a medical

appointment slip that was shorter and simpler than the

text in the Basic task.

Health tasks that mapped to the Intermediate level went

beyond simply searching texts and documents to find

information. Most health tasks that mapped to the

Intermediate level required adults to interpret or apply

information that was presented in complex graphs,

tables, or other health-related texts or documents.

Health tasks that mapped to the Proficient level required

drawing abstract inferences, comparing or contrasting

multiple pieces of information within complex texts or

documents, or applying abstract or complicated information from texts or documents.

Conducting the Survey4

The 2003 National Assessment of Adult Literacy

included two samples: (1) adults ages 16 and older living in households and (2) prison inmates ages 16 and

older in federal and state prisons.The assessment was

administered to approximately 19,000 adults: 18,000

adults living in households and 1,200 prison inmates.

Each sample was weighted to represent its share of the

total population of the United States, and the samples

were combined for reporting. Household data collection was conducted from March 2003 through

February 2004; prison data collection was conducted

from March through July 2004. For the household

sample, the screener response rate was 81 percent and

the background questionnaire response rate was 77

percent.The final household sample response rate was

62 percent.4 For the prison sample,97 percent of prisons that were selected for the study agreed to participate and the background questionnaire response rate

for prison inmates was 91 percent. The final prison

sample response rate was 88 percent.

Household interviews were conducted in respondents’ homes; prison interviews usually took place in

a classroom or library in the prison.Whenever possible, interviewers administered the background questionnaire and assessment in a private setting.

Assessments were administered one-on-one using a

computer-assisted personal interviewing (CAPI) 

system programmed into laptop computers.

Respondents were encouraged to use whatever aids

they normally used when reading and when performing quantitative tasks, including eyeglasses, magnifying glasses, rulers, and calculators.

Three percent of adults were unable to participate in

the assessment because they could not communicate

in either English or Spanish or because they had a

mental disability that prevented them from being

tested. Literacy scores for these adults could not be

estimated, and they are not included in the results

presented in this report, or in other NAAL reports.

An additional 3 percent of adults were routed to 

an alternative assessment (the Adult Literacy

Supplemental Assessment, or ALSA) based upon their

performance on the seven easy screening tasks at the

beginning of the literacy assessment. Because they

could be placed on the NAAL scale based on their

responses to the seven screening tasks,ALSA participants were classified into the Below Basic level on

each NAAL literacy scale. Results for the adults who

were placed in the ALSA are included in the results

presented in this report.

Additional information on ALSA, sampling,

response rates, and data collection procedures is in

appendix C. 4 Nonresponse bias analyses are discussed on page 34 of the report.

All percentages in this section are weighted. For the unweighted

percentages, see tables C-1 and C-2 in appendix C.
Interpretation of Results

The statistics presented in this report are estimates of

performance based on a sample of respondents,

rather than the values that could be calculated if

every person in the nation answered every question

on the assessment. Estimates of performance of the

population and groups within the population were

calculated by using sampling weights to account for

the fact that the probabilities of selection were not

identical for all respondents. Information about the

uncertainty of each statistic that takes into account

the complex sample design was estimated by using

Taylor series procedures to estimate standard errors.

The analyses in this report examine differences related

to literacy based on self-reported background characteristics among groups in 2003, by using standard t

tests to determine statistical significance. Statistical significance is reported at p < .05. Differences between

averages or percentages that are statistically significant

are discussed by using comparative terms such as

higher or lower. Differences that are not statistically

significant either are not discussed or are referred to

as “not statistically significant.” Failure to find a statistically significant difference should not be interpreted as meaning that the estimates are the same;

rather, failure to find a difference may also be due to

measurement error or sampling.

Detailed tables with estimates and standard errors for

all tables and figures in this report are in appendices

D and E. Appendix C includes more information

about the weights used for the sample and the procedures used to estimate standard errors and statistical significance.

Cautions in Interpretation

The purpose of this report is to examine the relationship between health literacy and various selfreported background factors. This report is purely

descriptive in nature. Readers are cautioned not to

draw causal inferences based solely on the results presented here. It is important to note that many of the

variables examined in this report are related to one

another, and complex interactions and relationships

have not been explored here.

Organization of the Report

Chapter 2 of this report examines how health literacy varied across groups with different demographic

characteristics, as well as the relationship between

health literacy and highest level of educational attainment and poverty status.

Chapter 3 explores the relationship between literacy

and overall health. The analyses in the chapter also

examine the literacy of adults who have different

types of health insurance or no health insurance.The

chapter concludes with an examination of the relationship between literacy and sources of printed and

nonprinted information used by adults.

8

The Health Literacy of America’s Adults
Demographic Characteristics and

Health Literacy

Data from the 2003 National Assessment of

Adult Literacy (NAAL) allow examinations of the relationships between demographic characteristics and literacy. Analyses from

the assessment showed differences in prose, document, and quantitative literacy for adults with different demographic characteristics. For example,

women had higher prose and document literacy

than men, while women’s average quantitative literacy was lower than men’s.The average prose, document, and quantitative literacy of White adults was

higher than the average literacy of adults of other

races or ethnicities.Adults 65 years of age and older

had the lowest average prose, document, and quantitative scores among all age groups (Kutner et al.

2005).

The relationships between health literacy and

demographic characteristics of adults are examined

in this chapter.Also examined are the relationships

between health literacy and highest level of educational attainment and poverty. All the analyses in

this chapter are based on the combined household

and prison samples.

9

Total Population

Gender

Race and Ethnicity

Language Spoken Before

Starting School

Age

Highest Level of Educational

Attainment

Poverty Threshold

Summary

CHAPTER TWO

2
10

The Health Literacy of America’s Adults

Total Population

The majority of adults, 53 percent, had Intermediate

health literacy (figure 2-1).An additional 22 percent

of adults had Basic health literacy, 14 percent had

Below Basic health literacy, and 12 percent had

Proficient health literacy. The distribution of adults

among the different health literacy levels is similar,

although not identical, to the distribution of adults

among the levels of the prose, document, and quantitative scales (Kutner et al. 2005).

Gender

The average health literacy score for women was

248, which is 6 points higher than the average health

literacy score for men (figure 2-2).A higher percentage of men than women had Below Basic health literacy, by a margin of 4 percentage points.The percentage of women with Intermediate health literacy was 

4 percentage points higher than the percentage of

men at the same level (figure 2-3). There were no

significant differences in the percentages of men and

women with Basic or Proficient health literacy.

Figure 2-3. Percentage of adults in each health 

literacy level, by gender: 2003

Below Basic Basic Intermediate Proficient 

16 22 51 11

12 21 55 12

80 40 20 60 0 20 40 60 80 100

Percent Below Basic Percent Basic and above 

Gender 

Women

Men

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

age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure.

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

Education Statistics, 2003 National Assessment of Adult Literacy.

Figure 2-1. Percentage of adults in each health 

literacy level: 2003

Below Basic Basic Intermediate Proficient 

80 40 20 60 0 20 40 60 80 100

Percent Below Basic Percent Basic and above 

All adults 14 22 53 12

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

age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure.

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

Education Statistics, 2003 National Assessment of Adult Literacy.

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

by gender: 2003

Men Women

242 248

0

150

200

250

Average score

300

350

500

Gender

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

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

percent in 2003) are excluded from this figure.

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

Education Statistics, 2003 National Assessment of Adult Literacy.
11

Chapter 2: Demographic Characteristics and Health Literacy

Race and Ethnicity

The average health literacy scores for different

racial/ethnic groups are shown in figure 2-4.White

and Asian/Pacific Islander adults had higher average

health literacy than Black, Hispanic, American

Indian/Alaska Native, and Multiracial adults.

Hispanic adults had lower average health literacy

than adults in any of the other racial/ethnic groups.

There was no significant difference in average health

literacy between White and Asian/Pacific Islander

adults. There was also no significant difference in

average health literacy between Black and American

Indian/Alaska Native adults.

The percentages of White and Asian/Pacific Islander

adults with Proficient health literacy were higher than

the percentages of Black, Hispanic, American

Indian/Alaska Native, or Multiracial adults with

Proficient health literacy (figure 2-5).

Fifty-eight percent of White, 52 percent of

Asian/Pacific Islander, and 59 percent of Multiracial

adults had Intermediate health literacy, compared with

41 percent of Black adults and 31 percent of Hispanic

adults. Conversely, higher percentages of Black and

Hispanic adults than White,Asian/Pacific Islander, or

Multiracial adults had Below Basic health literacy.

The percentages of Black, Hispanic, and Multiracial

adults with Basic health literacy were higher than the

percentages of White or Asian/Pacific Islander adults

with Basic health literacy.

Figure 2-4. Average health literacy scores of adults,

by race/ethnicity: 2003

0 

150 

200 

250 

Average score 

300 

350 

500 

Race/ethnicity

White Black Hispanic Asian/

Pacific 

Islander

American 

Indian/

Alaska Native

Multiracial

256

216

197

255

227

238

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

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

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

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

includes African American, and Hispanic includes Latino.

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

Education Statistics, 2003 National Assessment of Adult Literacy.

Figure 2-5. Percentage of adults in each health 

literacy level, by race/ethnicity: 2003

Below Basic Basic Intermediate Proficient 

80 40 20 60 0 20 40 60 80 100

Percent Below Basic Percent Basic and above 

Race/ethnicity 

Multiracial

American Indian/

Alaska Native

Asian/

Pacific Islander

Hispanic

Black

White 9

24 34 41 2

41 25 31 4

13

25

9 28 59 3

19 58 14

18 52 18

23 45 7

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

age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure.

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

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

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

Education Statistics, 2003 National Assessment of Adult Literacy.
The Health Literacy of America’s Adults

Language Spoken Before Starting School

Adults who spoke only English before starting school

had higher average health literacy than adults who

spoke only a language other than English before

starting school (table 2-1).The average health literacy score of adults who spoke only English before

starting school was at the Intermediate level, as were

the average health literacy scores of adults who spoke

English and Spanish or English and another language.Adults who spoke only Spanish before starting

school had the lowest average health literacy, equivalent to Below Basic health literacy.

Age

Adults in the oldest age group—65 and older—had

lower average health literacy than adults in younger age

groups (figure 2-6). Adults ages 25 to 39 had higher

average health literacy than adults in other age groups.

The percentages of adults with Intermediate health literacy in all age groups, except 65 and older, ranged

from 53 to 58 percent. Among adults ages 65 and

older, 38 percent had Intermediate health literacy. A

higher percentage of adults ages 65 or older had Below

Basic or Basic health literacy than adults in any of the

younger age groups (figure 2-7). Moreover, the percentages of adults in the 65 and older age group who

Figure 2-6. Average health literacy scores of adults,

by age: 2003

0

150

200

250

Average score

300

350

500

Age

16–18 19–24 25–39 40–49 50–64 65+

244 249 256 249 246

214

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

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

percent in 2003) are excluded from this figure.

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

Education Statistics, 2003 National Assessment of Adult Literacy.

Figure 2-7. Percentage of adults in each health 

literacy level, by age: 2003

Below Basic Basic Intermediate Proficient 

80 40 20 60 0 20 40 60 80 100

Percent Below Basic Percent Basic and above 

Age 

65+

50–64

40–49

25–39

19–24

16–18 11

10

10

11

13

29 30 38 3

23 58 8

21 58 11

18 55 16

21 56 12

21 53 12

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

age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure.

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

Education Statistics, 2003 National Assessment of Adult Literacy.

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

by language spoken before starting

school: 2003

Language spoken before starting school Average

English only 251

English and Spanish 232

English and other 244

Spanish 174

Other language 229

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

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

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

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

adults who spoke Spanish and additional non-English languages.

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

Education Statistics, 2003 National Assessment of Adult Literacy.

12
Figure 2-8. Average health literacy scores of adults, by highest educational attainment: 2003

241

184

232 232

241

253

264

280 287

0

150

200

250

Average score

300

350

500

Educational attainment

Still in high school Less than high school/

some high school

GED/high school 

equivalency

High school 

graduate

Vocational/trade/

business school

Some college Bachelor’s degree Graduate studies/

degree

Associate’s/

2-year degree

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

are excluded from this figure.

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

had Intermediate or Proficient health literacy were lower

than the percentages of adults in the other age groups

who had health literacy in those levels.A higher percentage of 25- to 39-year-old adults than adults in any

of the other age groups had Proficient health literacy.

The youngest adults, adults ages 16 to 18, were less

likely to have Proficient health literacy than adults ages

25 to 39 or adults ages 50 to 64.

Highest Level of Educational Attainment

Starting with adults who had graduated from high

school or obtained a GED, average health literacy

increased with each higher level of educational

attainment (figure 2-8). Adults who had not attended or completed high school, and were not currently enrolled in school, had lower average health literacy than adults with higher levels of education or

adults who were currently enrolled in high school.

A higher percentage of adults who had not attended or

completed high school had Below Basic health literacy

than adults in any other educational group (figure 2-9).

These same adults—adults who had not attended or

completed high school and were not currently enrolled

in school—were less likely than all other adults, except

for those who had a GED or high school equivalency

certificate, to have Proficient health literacy.

Higher percentages of adults who had taken some

graduate classes or completed a graduate degree, and

adults who had graduated from a 4-year college, had

Proficient health literacy than adults with lower levels of

education. However, there were no significant differences between the two highest educational groups

(adults with a bachelor’s degree and adults with graduate studies or a graduate degree) in the percentages of

adults falling in each of the four health literacy tasks.

Four percent of adults with an associate’s or 2-year

degree and 3 percent of adults with a 4-year college

degree or graduate studies had Below Basic health literacy, while 12 to 15 percent of adults who were still

in high school, had obtained a high school diploma,

had obtained a GED certificate, or had taken some

vocational, trade, or business classes after high school

had Below Basic health literacy.

13

Chapter 2: Demographic Characteristics and Health Literacy
14

The Health Literacy of America’s Adults

Poverty Threshold

Adults living below the poverty level had an average

health literacy score of 205, while adults living at the

poverty level or up to 125 percent of the poverty

level had an average health literacy score of 222

(table 2-2). Both of these average literacy scores are

in the Basic health literacy level.Average health literacy was highest for adults who were above 175 percent of the poverty threshold; in this group, average

health literacy was in the Intermediate range.5

Summary

The majority of adults, 53 percent, had Intermediate

health literacy.An additional 22 percent of adults had

Basic health literacy. Fewer than 15 percent of adults

had either Below Basic or Proficient health literacy.

Starting with adults who had graduated from high

school, or obtained a GED or high school equivalency certificate, average health literacy increased with

each higher level of education.Adults living below the

poverty level had lower average health literacy than

adults living above the poverty threshold.

Women had higher average health literacy than men.

White and Asian/Pacific Islander adults had higher

average health literacy than Black, Hispanic,American

Indian/Alaska Native, and Multiracial adults. Hispanic

adults had lower average health literacy than adults in

any of the other racial/ethnic groups. Adults who

spoke only English before starting school had a higher average health literacy than adults who spoke only

Spanish or another non-English language.Adults ages

65 and older had lower average health literacy than

adults in younger age groups.More adults ages 65 and

older also had Below Basic health literacy than adults

in any of the younger age groups.

Figure 2-9. Percentage of adults in each health 

literacy level, by highest educational

attainment: 2003

Below Basic Basic Intermediate Proficient 

Graduate studies/

degree

Bachelor’s degree

Some college

Vocational/trade/

business school

High school graduate

GED/high school

 equivalency

Less than/some

 high school

Still in high school 13

49 27 23 1

14 30 54 3

15 29 53 4

12

5

4

3

3

Associate’s/

2-year degree

24 56 7

25 57 7

20 67 8

15 66 15

10 60 27

8 57 33

80 40 20 60 0 20 40 60 80 100

Percent Below Basic Percent Basic and above 

Educational 

attainment 

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

age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure.

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

Education Statistics, 2003 National Assessment of Adult Literacy.

5 Analysis of average health literacy by occupation is presented in

appendix E.

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

by poverty threshold: 2003

Poverty threshold Average

Below poverty threshold 205

100–125% of poverty threshold 222

126–150% of poverty threshold 224

151–175% of poverty threshold 231

Above 175% of poverty threshold 261

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

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

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

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

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

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

the best matches possible based on the categorical data.

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

Education Statistics, 2003 National Assessment of Adult Literacy.
Overall Health, Health Insurance

Coverage, and Sources of Information

About Health Issues

Health literacy is of interest to providers of

health outreach programs for different segments of the population. These providers

may include health insurance companies and people

who are designing educational programs related to

health maintenance and improvement. A review of

medical and public health literature noted that literacy has a direct influence on patient “access to crucial information about their rights and their health

care, whether it involves following instruction for

care, taking medicine, comprehending disease-related information, or learning about disease prevention and health promotion” (Rudd et al. 1999).

This chapter examines the health literacy levels of

different populations who may be targeted by

health outreach programs, including adults with different levels of overall health and adults who have

different types of health insurance coverage or no

health insurance coverage at all.The analyses in the

chapter also explore where adults with different levels of health literacy get information about health

issues.

The analyses of the literacy of adults who received

various types of health insurance are based on the

household sample only. Analyses of adults who

received information about health issues from the

Internet are also based on the household sample only 

15

Self-Assessment of Overall

Health 

Health Insurance

Sources of Information About

Health Issues 

Summary

CHAPTER THREE

3
The Health Literacy of America’s Adults

because prison inmates generally do not have access to

the Internet.All other analyses in this chapter are based

on the combined household and prison samples.

This chapter focuses on the relationship between

health literacy and self-reported overall health, health

insurance coverage, and sources of information about

health issues. As shown in chapter 2, health literacy

varies across demographic groups (i.e., by sex,

race/ethnicity, age, and education). Overall health,

health insurance coverage, and sources of information

about health issues are also likely to vary across these

same demographic groups. Because of that, supplemental analyses showing the relationships between

health literacy and self-reported overall health, health

insurance coverage, and sources of information about

health issues broken out by demographic groups are

provided in appendix E.

Self-Assessment of Overall Health 

Figure 3-1 summarizes the average health literacy

scores for adults with different levels of self-reported overall health.At each higher level of self-reported level of overall health, adults had higher average

health literacy than adults in the next lower level.

The average health literacy score of adults who

reported excellent health was 262. Adults who

reported they had very good health had average

health literacy scores of 254; adults with self-reported good health had average health literacy scores of

234; adults with self-reported fair health had average

health literacy scores of 207; and adults with selfreported poor health had average health literacy

scores of 196 (figure 3-1).

Smaller percentages of adults who reported their

health was excellent or very good than adults who

reported their health was poor, fair, or good had Below

Basic health literacy (figure 3-2). Conversely, higher

percentages of adults who reported their overall health

Figure 3-1. Average health literacy scores of adults,

by self-assessment of overall health:

2003

196

207

234

254 262

0

150

200

250

Average score

300

350

500

Overall health

Poor Fair Good Very good Excellent

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

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

percent in 2003) are excluded from this figure.

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

Education Statistics, 2003 National Assessment of Adult Literacy.

16

Figure 3-2. Percentage of adults in each health 

literacy level, by self-assessment of

overall health: 2003

Below Basic Basic Intermediate Proficient

42 27 29 3

33 30 34 3

16

9

Excellent 8

Very good

Good

Fair

Poor

19 59 13

17 57 19

27 51 6

80 40 20 60 0 20 40 60 80 100

Percent Below Basic Percent Basic and above

Overall health

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

age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure.

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

Education Statistics, 2003 National Assessment of Adult Literacy.
was very good or excellent had Intermediate or

Proficient health literacy than adults who said their

overall health was poor, fair, or good.

Most differences within health literacy levels in figure 3-2 are significant. However, significant differences were not detected between the percentages of

adults with self-reported excellent health and very

good health with Below Basic and Intermediate health

literacy, between the percentages of adults with selfreported good health and poor health with Basic

health literacy, and between the percentages of adults

with self-reported fair health and poor health with

Proficient health literacy.

Health Insurance

Adults in the United States may receive health

insurance through a variety of public and private

sources. These include group insurance that is provided through an employer of the individual or a

family member, military insurance for active or

retired service members and their families, privately

purchased individual insurance policies, or insurance

through a government program. The two major

government programs that provide health insurance

are Medicare and Medicaid. Medicare provides coverage for most adults ages 65 and older in the

United States, in addition to some younger adults

with disabilities. Medicaid coverage is limited to

low-income adults who also meet other criteria that

vary by state.

Adults who received health insurance through an

employer had higher average health literacy than

adults who received health insurance through other

sources or adults who had no health insurance (figure 3-3).Adults who received Medicare or Medicaid

and adults who had no health insurance coverage had

lower average health literacy than adults who were

covered by other types of health insurance.

Among adults who received Medicare or Medicaid,

27 percent and 30 percent, respectively, had Below

Basic health literacy (figure 3-4). Twenty-eight percent of adults who had no health insurance had

Below Basic health literacy. Among adults who

received employer-provided, military, or privately

purchased health insurance, the percentages with

Below Basic health literacy were lower, 7 percent, 12

percent, and 13 percent, respectively.

Among adults who received employer-provided

health insurance, 62 percent had Intermediate health

literacy and 14 percent had Proficient health literacy

(figure 3-4).The percentages of adults who received

Medicare or Medicaid and had Intermediate or

Proficient health literacy were lower than those who

received other types of health insurance.

Figure 3-3. Average health literacy scores of adults,

by type of health insurance coverage:

2003

Employer 

provided

Military Privately 

purchased

Medicare Medicaid No insurance

259

248 243

216 212 220

0

150

200

250

Average score

300

350

500

Type of health insurance

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

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

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

insurance are included in each applicable category in this figure.

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

Education Statistics, 2003 National Assessment of Adult Literacy.

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

17
Sources of Information About Health Issues 

Adults may get health information in a variety of

ways, including through traditional (newspapers,

magazines, and books or brochures) and nontraditional (the Internet) forms of print media and

through nonprint media (radio and television).

Adults may also get information about health issues

from conversations with family, friends, or coworkers

or conversations with health care professionals.

Printed and Written Media

Many adults receive information about health issues

from such traditional printed sources as newspapers,

magazines, and books or brochures. America’s adults

also have access to a huge amount of written health

information on the Internet.A recent Harris Poll estimates that roughly 100 million adults go online to

find health information (Taylor 2001).Another study

found that 70 percent of consumers reported having

made a health care decision on the basis of information they found online (Fox and Rainie 2000).

Lower percentages of adults with Below Basic health

literacy than adults with Basic, Intermediate, or

Proficient health literacy reported that they got information about health issues from any written sources,

including newspapers, magazines, books or

brochures, and the Internet (figure 3-5).Twenty percent of adults with Below Basic health literacy got

information about health issues from the Internet,

compared with 42 percent of adults with Basic health

literacy, 67 percent of adults with Intermediate health

literacy, and 85 percent of adults with Proficient health

literacy. Lower percentages of adults with Below Basic,

Basic, or Intermediate health literacy got information

about health issues from the Internet than from other

written sources (figure 3-5).

A higher percentage of adults with Proficient health

literacy than adults with lower levels of health literacy got a lot of information about health issues from

the Internet. Higher percentages of adults with Basic

or Intermediate health literacy than adults with either

lower (Below Basic) or higher (Proficient) health literacy got a lot of information about health issues from

newspapers and magazines. Higher percentages of

adults with Basic, Intermediate, or Proficient health literacy than adults with Below Basic health literacy got

a lot of information about health issues from books

or brochures.

Higher percentages of adults with Proficient health

literacy got information about health issues from

books or brochures than from newspapers or the

Internet. Additionally, higher percentages of adults

The Health Literacy of America’s Adults

18

Figure 3-4. Percentage of adults in each health 

literacy level, by type of health 

insurance coverage: 2003

Below Basic Basic Intermediate Proficient

80 40 20 60 0 20 40 60 80 100

Percent Below Basic Percent Basic and above

Type of health

 insurance

7

12

13

27

30

No insurance 28

Medicaid

Medicare

Privately purchased

Military

Employer provided 17 62 14

21 56 11

24 54 9

30 40 3

30 38 3

25 41 7

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

age and older living in households. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure. Adults who

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

in this figure.

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

Education Statistics, 2003 National Assessment of Adult Literacy.
19

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

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

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

41

22 14 12

Newspapers Magazines

A lot Some A little None

Books or brochures Internet

Percent got no 

 information 

Percent got 

 information 

0

20

20

40

40

60

60

80

80

100

100

Below Basic Basic Intermediate Proficient

Literacy level 

Percent got no 

 information 

Percent got 

 information 

0

20

20

40

40

60

60

80

80

100

100

Below Basic Basic Intermediate Proficient

Literacy level 

Percent got no

 information

Percent got

 information

0

20

20

40

40

60

60

80

80

100

100

Below Basic Basic Intermediate Proficient

Literacy level

Percent got no

 information

Percent got

 information

0

20

20

40

40

60

60

80

80

100

100

Below Basic Basic Intermediate Proficient

Literacy level

37

24 19 20

41

20 13 11

80

58

33

15

29

22

12

35

27

15

36

31

14

32

38

10

27

23

10

37

25

17

41

28

18

40

35

12

7 5

7 16

12

14 27

19

21

37

22

26

28

21

11

39

25

16

41

28

18

36

35

18

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

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

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
with Proficient health literacy got information

about health issues from the Internet than from

newspapers.

Nonprint Media

Higher percentages of adults with Below Basic or

Basic health literacy than adults with Intermediate

health literacy received a lot of information about

health issues from radio and television. Adults with

Proficient health literacy were least likely to receive a

lot of information about health issues from those

same nonprint media sources (figure 3-6).

Personal Contacts

With each higher level of health literacy, a higher

percentage of adults got information about health

issues from family members, friends, or coworkers

(or, in the case of prison inmates, from family members, friends, other inmates, or staff) (figure 3-7).

Higher percentages of adults with Intermediate or

Proficient health literacy than adults with Basic health

literacy got any information about health issues from

health care professionals, including doctors, nurses,

therapists, and psychologists. A higher percentage of

adults with Basic health literacy than adults with

Below Basic health literacy got any information about

these issues from health care professionals.

Summary

At every higher self-reported level of overall health

(poor, fair, good, very good, excellent), adults had

higher average health literacy than adults in the next

lower level. Smaller percentages of adults who reported that their overall health was very good or excellent

had Below Basic health literacy than other adults.

Adults who received Medicare or Medicaid or who

had no health insurance had lower average health literacy than adults who received insurance through an

employer or the military or adults who purchased

private insurance. Among adults who received

Medicare and Medicaid, 27 percent and 30 percent,

respectively, had Below Basic health literacy.

A lower percentage of adults with Below Basic health

literacy than adults with Basic,Intermediate,or Proficient

health literacy reported that they got information

about health issues from any written sources, including newspapers, magazines, books or brochures, and

20

The Health Literacy of America’s Adults

Figure 3-6. Percentage of adults who got information

about health issues from nonprint media:

radio and television, by health literacy

level: 2003

A lot Some A little None 

Percent got no 

 information 

Percent got 

 information 

0

20

20

40

40

60

60

80

80

100

100

Below Basic Basic Intermediate Proficient

Literacy level 

33

34

19

14

25

44

24

7

17

43

30

8 9

31

40

21

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

age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure.

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

Education Statistics, 2003 National Assessment of Adult Literacy.
the Internet. A higher percentage of adults with

Proficient health literacy than adults with lower levels

of health literacy got a lot of information about

health issues from the Internet.A lower percentage of

adults with Below Basic, Basic, and Intermediate health

literacy got information about health issues from the

Internet than from other written sources.

A lower percentage of adults with Proficient health literacy than adults with Intermediate health literacy

received a lot of information about health issues from

radio or television, and a lower percentage of adults

with Intermediate health literacy than adults with Basic

or Below Basic health literacy received a lot of information about health issues from radio or television.

With each higher level of health literacy, the percentage of adults who got information about health issues

from personal contacts other than health care professionals was higher.

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

21

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

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

18 11 8 8

24 15 9

Family, friends, or coworkers 

(household only), 

other inmates (prison only), 

or staff (prison only) Health care professionals

A lot Some A little None 

36

29

17

37

33

19

34

37

21

30

39

23

19

35

23

20

40

25

19

44

28

17

48

31

5

Percent got no 

 information 

Percent got 

 information 

0

20

20

40

40

60

60

80

80

100

100

Below Basic Basic Intermediate Proficient

Literacy level 

Percent got no 

 information 

Percent got 

 information 

0

20

20

40

40

60

60

80

80

100

100

Below Basic Basic Intermediate Proficient

Literacy level 

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

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

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

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

Sample Health Literacy 

Assessment Question

Respondents who participated in the 2003

assessment were asked to complete prose,

document, and quantitative literacy tasks

of varying levels of difficulty.The sample question

on the following page illustrates the type of task

used to measure the health literacy of America’s

adults.This question was originally developed for

the 1992 survey and reused in 2003.

Consistent with the design of the assessment, the

sample question appears before the text needed to

answer the question. The percentage of respondents who answered the question correctly is

reported, as well as the percentage of correct

responses for each of the four health literacy assessment levels.

More information about the sample assessment

questions can be found on the Internet at

http://nces.ed.gov/naal.

23

APPENDIX A

A
24

The Health Literacy of America’s Adults

Prose and Health Literacy Question

Refer to the article on the next page to answer the following question.

According to the brochure, why is it difficult for people to know if they have high blood pressure?

_______________________________________________________________________________

_______________________________________________________________________________

Correct answer

Any statement such as the following:

Symptoms are not usually present

High blood pressure is silent

All Adults Below Basic Basic Intermediate Proficient

74 10 71 94 100

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

are excluded from these data.

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

Percentage of adults who answered the question correctly, health literacy scale: 2003
25

Appendix A: Sample Health Literacy Assessment Question

Definitions of All Subpopulations 

and Background Variables Reported

For the exact wording of background 

questions, see http://nces.ed.gov/naal.

Chapter 2

Total Population

The 2003 National Assessment of Adult Literacy

included two samples: (1) adults ages 16 and older

living in households and (2) inmates ages 16 and

older in federal and state prisons. The household

sample also included adults in six states that chose

to participate in a concurrent State Assessment of

Adult Literacy: Kentucky, Maryland, Massachusetts,

Missouri, Oklahoma, and New York. Each sample

was weighted to represent its share of the total

population of the United States (99 percent for the

household sample and 1 percent for the prison

sample). The household and prison samples were

combined to create a nationally representative

sample of America’s adults. Household data collection was conducted from March 2003 through

February 2004; prison data collection was conducted from March through July 2004.

27

APPENDIX B

B
Gender

Interviewers recorded the gender of each respondent.

Race and Ethnicity

In 2003, all respondents were asked two or three

questions about their race and ethnicity. The first

question asked them to indicate whether they were

Hispanic or Latino.

If a respondent answered that he or she was Hispanic

or Latino, the respondent was asked to choose one or

more of the following groups to describe his or her

Hispanic origin:

■ Mexican, Mexican American, or Chicano

■ Puerto Rican or Puerto Rican American

■ Cuban or Cuban American

■ Central or South American

■ Other Hispanic or Latino background

Respondents who identified more than one of the

groups to describe their Hispanic origin were classified as “Other Hispanic or Latino background.”

Then, all respondents, including those who indicated

they were Hispanic or Latino, were asked to choose

one or more of the following groups to describe

themselves:

■ White

■ Black or African American

■ Asian

■ American Indian or Alaska Native

■ Native Hawaiian or other Pacific Islander

Individuals who responded “yes” to the first question

were coded as Hispanic, regardless of their answer to

the second question. Individuals who identified

more than one group on the second question were

coded as Multiracial. Respondents of Native

Hawaiian or Pacific Islander origin were grouped

with those of Asian origin. The White, Black, and

Hispanic groups are reported separately. The interviewer recorded the race/ethnicity of respondents

who refused to answer the question.

Age

All respondents were asked to report their birth

dates, and this information was used to calculate their

age. Age groups reported are 16 to 18, 19 to 24, 25

to 39, 40 to 49, 50 to 64, and 65 and older. Age

groups were selected to correspond to key life stages

of many adults:

16-18: Completion of secondary education

19-24: College or job training

25-39: Early career

40-49: Mid-career

50-64: Late career

65 and older: Retirement 

Highest Level of Educational Attainment

All respondents were asked to indicate the highest

level of education they had completed.The following

options were provided:

■ Still in high school

■ Less than high school 

■ Some high school 

■ GED or high school equivalency

■ High school graduate

■ Vocational, trade, or business school after high

school

■ College: less than 2 years

■ College:Associate’s degree (A.A.)

■ College: 2 or more years, no degree

■ College graduate (B.A. or B.S.)

28

The Health Literacy of America’s Adults
■ Postgraduate, no degree

■ Postgraduate degree (M.S., M.A., Ph.D., M.D.,

etc.)

Respondents who reported less than high school or

some high school were asked how many years of

education they completed. For certain analyses, some

of these groups were collapsed. For example, respondents who reported some postgraduate study but no

degree were generally combined with those who had

completed a postgraduate degree.

Chapter 3

Self-Assessment of Overall Health

Respondents were asked how, in general, they would

rate their overall health.They were given the following response options: excellent, very good, good,

fair, poor.

Health Insurance

Respondents were asked whether they received the

following types of health insurance: health insurance

through your work (school) or a family member’s

work,Medicare,health insurance you or someone else

in your family purchased directly from an insurance

company or other organization that is not related to

past or current employment, health insurance provided as part of military service, Medicaid. Respondents

could indicate that they received multiple types of

health insurance.Adults who received more than one

type of health insurance were included in multiple

categories for the analyses in this report. Adults in

prisons were not asked this question and they are not

included in the analyses.

Sources of Information About Health Issues

Household respondents were asked how much information about health issues, such as diet, exercise, disease prevention, or a specific disease or health condition, they got from newspapers, magazines, the

Internet, radio and television, books or brochures;

family members, friends, or coworkers; or talking to

doctors, nurses, therapists, or psychologists. They

were given the following response options: a lot,

some, a little, none. Prison respondents were asked

the same question, but instead of “family members,

friends, or coworkers,” they were asked about “family members, friends, other inmates, or staff.” Prison

respondents were not asked about the Internet

because most prison inmates do not have access to

the Internet.

29

Appendix B: Definitions of All Subpopulations and Background Variables Reported

31

toc

CHAPTER ONE

1

Technical Notes

This appendix describes the sampling, data

collection, weighting and variance estimation, scaling, and statistical testing procedures used to collect and analyze the data for the

2003 National Assessment of Adult Literacy

(NAAL). Household data collection was conducted from March 2003 through February 2004;

prison data collection was conducted from March

through July 2004.

Sampling 

The 2003 National Assessment of Adult Literacy

included two samples: (1) adults ages 16 and older

living in households (99 percent of the sample

weighted) and (2) inmates ages 16 and older in federal and state prisons (1 percent of the sample

weighted). Each sample was weighted to represent

its share of the total population of the United States,

and the samples were combined for reporting.

Household Sample

The 2003 National Assessment of Adult Literacy

household sample included a nationally representative probability sample of 35,365 households.

The household sample was selected on the basis of

a four-stage, stratified area sample: (1) primary

sampling units (PSUs) consisting of counties or

groups of contiguous counties; (2) secondary sampling units (referred to as segments) consisting of

area blocks; (3) housing units containing households; and (4) eligible persons within households.

Person-level data were collected through a screener,

APPENDIX C

C
a background questionnaire, the literacy assessment,

and the oral module. Of the 35,365 sampled households,4,671 were either vacant or not a dwelling unit,

resulting in a sample of 30,694 households.1A total of

25,123 households completed the screener, which

was used to select survey respondents. The final

screener response rate was 81.2 percent weighted.

On the basis of the screener data, 23,732 respondents

ages 16 and older were selected to complete the

background questionnaire and the assessment;18,186

actually completed the background questionnaire. Of

the 5,546 respondents who did not complete the

background questionnaire, 355 were unable to do so

because of a literacy-related barrier, either the inability to communicate in English or Spanish (the two

languages in which the background questionnaire

was administered) or a mental disability.

The final response rate for the background questionnaire, which included respondents who completed

the background questionnaire and respondents who

were unable to complete the background questionnaire because of language problems or a mental disability, was 76.6 percent weighted. Of the 18,186

adults ages 16 and older who completed the background questionnaire, 17,178 completed at least one

question on each of the three scales—prose, document, and quantitative—measured in the adult literacy assessment. An additional 149 were unable to

answer at least one question on each of the three

scales for literacy-related reasons.2The final response

rate for the literacy assessment, which included

respondents who answered at least one question on

each scale plus the 149 respondents who were unable

to do so because of language problems or a mental

disability, was 96.6 percent weighted.

Cases were considered complete if the respondent

completed the background questionnaire and at least

one question on each of the three scales or if the

respondent was unable to answer any questions

because of language issues (an inability to communicate in English or Spanish) or a mental disability. All

other cases that did not include a complete screener,

a background questionnaire, and responses to at least

one question on each of the three literacy scales were

considered incomplete or missing. Before imputation, the overall response rate for the household sample was 60.1 percent weighted.

For respondents who did not complete any literacy

tasks on any scale, no information is available about

their performance on the literacy scale they were

missing. Completely omitting these individuals from

the analyses would have resulted in unknown biases

in estimates of the literacy skills of the national population because refusals cannot be assumed to have

occurred randomly. For 859 respondents3 who

answered the background questionnaire but refused to

complete the assessment for reasons other than language issues or a mental disability, regression-based

imputation procedures were applied to impute

responses to one assessment item on each scale by

using the NAAL background data on age, gender,

race/ethnicity, education level, country of birth, census region, and metropolitan statistical area status.

On the prose and quantitative scales, a response was

imputed for the easiest task on each scale. On the

32

The Health Literacy of America’s Adults

3 Of the 18,186 household respondents who completed the background questionnaire, 17,178 completed at least one question on

each of the three scales and 149 were unable to answer at least one

question on one or more of the scales for literacy-related reasons.

The remaining 859 respondents completed the background questionnaire but refused to complete the assessment.

1To increase the number of Black and Hispanic adults in the NAAL

sample, segments with moderate to high concentrations of Black

and Hispanic adults were given a higher selection probability.

Segments in which Blacks or Hispanics accounted for 25 percent

or more of the population were oversampled at a rate up to three

times that of the remainder of the segments.

2 Of the 149 respondents who were unable to answer at least one

question on each of the three scales for literacy-related reasons, 65

respondents answered at least one question on one scale. The

remaining 84 respondents did not answer any questions on any scale.
document scale, a response was imputed for the second easiest task because that task was also included on

the health literacy scale. In each of the logistic regression models, the estimated regression coefficients

were used to predict missing values of the item to be

imputed. For each nonrespondent, the probability of

answering the item correctly was computed and then

compared with a randomly generated number

between 0 and 1. If the probability of getting a correct answer was greater than the random number, the

imputed value for the item was 1 (correct).Otherwise

it was 0 (wrong). In addition, a wrong response on

each scale was imputed for 65 respondents who started to answer the assessment but were unable to

answer at least one question on each scale because of

language issues or a mental disability.4

The final household reporting sample—including

the imputed cases—consisted of 18,102 respondents.

These 18,102 respondents are the 17,178 respondents who completed the background questionnaire

and the assessment, plus the 859 respondents who

completed the background questionnaire but refused

to do the assessment for non-literacy-related reasons

and have imputed responses to one item on each

scale, plus the 65 respondents who started to answer

the assessment items but were unable to answer at

least one question on each scale because of language

issues or a mental disability.After including the cases

for which responses to the assessment questions were

imputed, the weighted response rate for the household sample was 62.1 percent (18,102 cases with

complete or imputed data and an additional 439

cases that had no assessment data because of language

issues or a mental disability).5

The household sample was subject to unit nonresponse from the screener, background questionnaire,

literacy assessment, and oral module and to item

nonresponse to background questionnaire items.

Although all background questionnaire items had

response rates of more than 85 percent, two stages of

data collection—the screener and the background

questionnaire—had unit response rates below 85

percent and thus required an analysis of the potential for nonresponse bias.

Table C-1 presents a summary of the household

response rate.

Prison Sample

The 2003 assessment also included a nationally representative probability sample of inmates in federal and

state prisons. A total of 114 prisons were selected to

participate in the adult literacy assessment. Of these

114 prisons, 107 agreed to participate, 3 refused, and

4 were ineligible. The final prison response rate was

97.3 percent weighted. From among the inmates in

those prisons, 1,298 inmates ages 16 and older were

randomly selected to complete the background questionnaire and assessment. Of those 1,298 selected

inmates, 1,161 completed the background questionnaire. Of the 137 who did not complete the background questionnaire, 12 were unable to do so

because of a literacy-related barrier, either the inabil33

Appendix C: Technical Notes

Table C-1. Weighted and unweighted household

response rate, by survey component: 2003

Weighted Unweighted

Response rate Response rate

Survey component (percent) (percent)

Screener 81.2 81.8

Background questionnaire 76.6 78.1

Literacy assessment 96.6 97.2

Overall response rate before imputation 60.1 62.1

Overall response rate after imputation 62.1 63.9

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

Education Statistics, 2003 National Assessment of Adult Literacy.

4 For a more detailed discussion of imputation see Little and

Rubin (2002).

5 The 439 cases that had no assessment data because of language

issues or a mental disability include the 355 respondents who were

unable to complete the background questionnaire for one of these

reasons, plus the 84 respondents who did not answer any questions

on any scale because of language issues or a mental disability.
ity to communicate in English or Spanish (the two

languages in which the background questionnaire

was administered) or a mental disability.

The final response rate for the prison background

questionnaire, which included respondents who

completed the background questionnaire and

respondents who were unable to complete the background questionnaire because of language problems

or a mental disability, was 90.6 percent weighted. Of

the 1,161 inmates who completed the background

questionnaire, 1,125 completed at least one question

on each of the three scales—prose, document, and

quantitative—measured in the adult literacy assessment. An additional eight were unable to answer at

least one question on each of the three scales for literacy-related reasons.The final response rate for the

literacy assessment, which included respondents who

answered at least one question on each scale or were

unable to do so because of language problems or a

mental disability, was 98.9 percent weighted.

The same definition of a complete case used for the

household sample was also used for the prison sample, and the same rules were followed for imputation.

Before imputation, the final response rate for the

prison sample was 87.2 percent weighted.

One response on each scale was imputed on the basis

of background characteristics for 28 inmates who

completed the background questionnaire but had

incomplete or missing assessments for reasons that

were not literacy related. The statistical imputation

procedures were the same as for the household sample. The background characteristics used for the

missing data imputation for the prison sample were

prison security level, region of country/prison type,

age, gender, educational attainment, country of birth,

race/ethnicity, and marital status. A wrong response

on each scale was imputed for the three inmates who

started to answer the assessment but were unable to

answer at least one question on each scale because of

language issues or a mental disability.The final prison

reporting sample—including the imputed cases—

consisted of 1,156 respondents. After the cases for

which responses to the assessment questions were

imputed were included, the weighted response rate

for the prison sample was 88.3 percent (1,156 cases

with complete or imputed data and an additional 17

cases that had no assessment data because of language

issues or a mental disability).

Table C-2 presents a summary of the prison response

rate.

Nonresponse Bias

NCES statistical standards require a nonresponse bias

analysis when the unit response rate for a sample is less

than 85 percent.The nonresponse bias analysis of the

household sample revealed differences in the background characteristics of respondents who participated

in the assessment compared with those who refused.

In bivariate unit-level analyses at the screener and

background questionnaire stages, estimated percentages for respondents were compared with those for

the total eligible sample to identify any potential bias

owing to nonresponse. Although some statistically

significant differences existed, the potential for bias

was small because the absolute difference between

estimated percentages was less than 2 percent for all

domains considered. Multivariate analyses were con34

The Health Literacy of America’s Adults

Table C-2. Weighted and unweighted prison

response rate, by survey component: 2003

Weighted Unweighted

Response rate Response rate

Survey component (percent) (percent)

Prison 97.3 97.3

Background questionnaire 90.6 90.4

Literacy assessment 98.9 98.8

Overall response rate before imputation 87.2 86.8

Overall response rate after imputation 88.3 87.9

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

Education Statistics, 2003 National Assessment of Adult Literacy.
ducted to further explore the potential for nonresponse bias by identifying the domains with the most

differential response rates. These analyses revealed

that the lowest response rates for the screener were

among dwelling units in segments with high median

income, small average household size, and a large

proportion of renters. The lowest response rates for

the background questionnaire were among males

ages 30 and older in segments with high median

income. However, the variables used to define these

areas and other pockets with low response rates were

used in weighting adjustments. The analysis showed

that weighting adjustments was highly effective in

reducing the bias.The general conclusion was that the

potential amount of nonresponse bias attributable to

unit nonresponse at the screener and background

questionnaire stages was likely to be negligible.

Data Collection 

Household interviews took place in respondents’

homes; prison interviews generally took place in a

classroom or library in the prison. Whenever possible, interviewers administered the background questionnaire and assessment in a private setting. Unless

there were security concerns, a guard was not present in the room when inmates were interviewed.

Interviewers used a computer-assisted personal interviewing (CAPI) system programmed into laptop

computers. The interviewers read the background

questions from the computer screen and entered all

responses directly into the computer.Skip patterns and

follow-up probes for contradictory or out-of-range

responses were programmed into the computer.

After completing the background questionnaire,

respondents were handed a booklet with the assessment questions. The interviewers followed a script

that introduced the assessment booklet and guided

the respondent through the assessment.

Each assessment booklet began with the same seven

questions. After the respondent completed those

questions, the interviewer asked the respondent for

the book and used an algorithm to determine on the

basis of the responses to the first seven questions

whether the respondent should continue in the main

assessment or be placed in the Adult Literacy

Supplemental Assessment (ALSA). Three percent of

adults weighted (5 percent unweighted) were placed

in the ALSA.

ALSA was a performance-based assessment that

allowed adults with marginal literacy to demonstrate

what they could and could not do when asked to

make sense of various forms of print.The ALSA

started with simple identification tasks and sight

words and moved to connected text, using authentic, highly contextualized material commonly found

at home or in the community. Respondents placed

in the ALSA are included in the NAAL sample

based on their responses to the seven questions

Because the ALSA respondents got most or all of the

seven questions at the beginning of the assessment

wrong, they would have been classified into the

Below Basic level on the health scale.

A respondent who continued in the main assessment

was given back the assessment booklet, and the interviewer asked the respondent to complete the tasks in

the booklet and guided the respondent through the

tasks.The main assessment consisted of 12 blocks of

tasks with approximately 11 questions in each block,

but each assessment booklet included only 3 blocks

of questions.The blocks were spiraled so that across

the 26 different configurations of the assessment

booklet, each block was paired with every other

block and each block appeared in each of the three

positions (first, middle, last) in a booklet.

For ALSA interviews, the interviewer read the ALSA

script from a printed booklet and classified the

respondent’s answers into the response categories in

35

Appendix C: Technical Notes
the printed booklet.ALSA respondents were handed

the materials they were asked to read

Following the main assessment or ALSA, all respondents were administered the oral fluency assessment

(not discussed in this report).Respondents were handed a booklet with passages, number lists, letter lists,

word lists, and pseudoword lists to read orally.

Respondents read into a microphone that recorded

their responses on the laptop computer.

Weighting and Variance Estimation

A complex sample design was used to select assessment respondents.The properties of a sample selected through a complex design could be very different from those of a simple random sample in which

every individual in the target population has an

equal chance of selection and in which the observations from different sampled individuals can be considered to be statistically independent of one another. Therefore, the properties of the sample for the

complex data collection design were taken into

account during the analysis of the data. Standard

errors calculated as though the data had been collected from a simple random sample would generally

underestimate sampling errors. One way of addressing the properties of the sample design was by using

sampling weights to account for the fact that the

probabilities of selection were not identical for all

respondents.All population and subpopulation characteristics based on the NAAL data used sampling

weights in their estimation.

The statistics presented in this report are estimates of

group and subgroup performance based on a sample

of respondents, rather than the values that could be

calculated if every person in the nation answered

every question on the instrument. It is therefore

important to have measures of the degree of uncertainty of the estimates. Accordingly, in addition to

providing estimates of percentages of respondents

and their average scale score, this report provides

information about the uncertainty of each statistic.

Because the assessment used clustered sampling, conventional formulas for estimating sampling variability that assume simple random sampling and hence

independence of observations are inappropriate. For

this reason, the NAAL assessment uses a Taylor series

procedure based on the sandwich estimator to estimate

standard errors (Binder 1983).

Scaling

As discussed above, each respondent to the NAAL

received a booklet that included 3 of the 13 assessments blocks. Because each respondent did not

answer all of the NAAL items, item response theory

(IRT) methods were used to estimate average scores

on the health, prose, document, and quantitative 

literacy scales;a simple average percent correct would

not allow for reporting results that are comparable

for all respondents. IRT models the probability of

answering a question correctly as a mathematical

function of proficiency or skill. The main purpose

of IRT analysis is to provide a common scale on

which performance on some latent trait can be 

compared across groups, such as those defined by sex,

race/ethnicity, or place of birth (Hambleton and

Swaminathan 1985).

IRT models assume that an examinee’s performance

on each item reflects characteristics of the item and

characteristics of the examinee. All models assume

that all items on a scale measure a common latent

ability or proficiency dimension (e.g., prose literacy)

and that the probability of a correct response on an

item is uncorrelated with the probability of a correct

response on another item given fixed values of the

latent trait. Items are measured in terms of their difficulty as well as their ability to discriminate among

examinees of varying ability.

36

The Health Literacy of America’s Adults
The assessment used two types of IRT models to

estimate scale scores. The two-parameter logistic

(2PL) model, which was used for dichotomous items

(that is, items that are scored either right or wrong)

takes the form

,

where is the response of person j to item i, is

the proficiency of person j, is the slope or discrimination parameter for item i, and is the location or

difficulty parameter for item i.

For the partial credit items, the graded response

logistic (GRL) model was used. This model follows

the 2PL model for the probability of a score of 1 (at

least partially correct):

.

It also follows the 2PL model for the probability of a

score of 2 (completely correct):

.

In the equations above, and are the step

parameters corresponding to the response categories

of partially or fully correct.

The scale indeterminacy was solved by setting an origin and unit size to the reported scale means and

standard deviations from the 1992 assessment.6 Linear

transformation was performed to transform the original scale metric to the final reporting metric.

Levels were set and items were mapped to scales based

on the scores corresponding to a 67 percent success

rate on the tasks.

Statistical Testing

The statistical comparisons in this report were based

on the t statistic.Statistical significance was determined

by calculating a t value for the difference between a

pair of means, or proportions, and comparing this

value with published tables of values at a certain level

of significance, called alpha level.The alpha level is an

a priori statement of the probability of inferring that

a difference exists when, in fact, it does not. The

alpha level used in this report is .05, based on a twotailed test.The formula used to compute the t statistic was as follows:

,

where and are the estimates to be compared

and and are their corresponding standard

errors.

37

Appendix C: Technical Notes

6 The means for the 1992 assessment were 276 for prose, 271 for

document, and 275 for quantitative.The standard deviations for the

1992 assessment were 61 for prose, 61 for document, and 66 for

quantitative.The standard deviations for the 2003 assessment were

59 for prose, 57 for document, and 61 for quantitative.

39

toc

CHAPTER ONE

1

Standard Errors 

for Tables and Figures

APPENDIX D

D
40

The Health Literacy of America’s Adults

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

2003

Gender Average

Men 242 (1.3)

Women 248 (1.5)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

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

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

gender: 2003

Gender Below Basic Basic Intermediate Proficient

Men 16 (0.6) 22 (0.4) 51 (0.7) 11 (0.5)

Women 12 (0.7) 21 (0.6) 55 (0.8) 12 (0.7)

NOTE: Detail may not sum to totals because of rounding. Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table.

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

Table D2-4. Estimates and standard errors for Figure 2-4. Average health literacy scores of adults, by 

race/ethnicity: 2003

Race/ethnicity Average

White 256 (1.4)

Black 216 (2.1)

Hispanic 197 (3.3)

Asian/Pacific Islander 255 (5.6)

American Indian/Alaska Native 227 (10.3)

Multiracial 238 (3.9)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table. All adults of Hispanic origin are classified as Hispanic, regardless of race.The Asian/Pacific Islander category includes Native Hawaiians.

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

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

Literacy level Percentage

Below Basic 14 (0.5)

Basic 22 (0.4)

Intermediate 53 (0.6)

Proficient 12 (0.5)

NOTE: Detail may not sum to totals because of rounding. Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
41

Appendix D: Standard Errors for Tables and Figures

Table D2-5. Estimates and standard errors for Figure 2-5. Percentage of adults in each health literacy level, by

race/ethnicity: 2003

Race/ethnicity Below Basic Basic Intermediate Proficient

White 9 (0.6) 19 (0.7) 58 (0.9) 14 (0.9)

Black 24 (2.1) 34 (1.5) 41 (2.3) 2 (0.5)

Hispanic 41 (1.7) 25 (0.6) 31 (1.2) 4 (0.4)

Asian/Pacific Islander 13 (2.1) 18 (1.6) 52 (2.4) 18 (2.5)

American Indian/Alaska Native 25 (5.4) 23 (2.8) 45 (5.2) 7 (2.9)

Multiracial 9 (3.7) 28 (4.7) 59 (6.1) 3 (2.3)

NOTE: Detail may not sum to totals because of rounding. Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table. All adults of Hispanic origin are classified as Hispanic, regardless of race.The Asian/Pacific

Islander category includes Native Hawaiians.

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

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

spoken before starting school: 2003

Language spoken before starting school Average

English only 251 (1.2)

English and Spanish 232 (3.6)

English and other 244 (4.3)

Spanish 174 (4.2)

Other language 229 (6.4)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.The English and Spanish category includes adults who spoke languages in addition to both English and Spanish.The Spanish category includes

adults who spoke Spanish and additional non-English languages.

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

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

Age Average

16–18 244 (3.6)

19–24 249 (2.5)

25–39 256 (1.6)

40–49 249 (1.9)

50–64 246 (2.1)

65+ 214 (2.0)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
42

The Health Literacy of America’s Adults

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

age: 2003

Age Below Basic Basic Intermediate Proficient

16–18 11 (2.0) 23 (2.3) 58 (2.9) 8 (2.0)

19–24 10 (1.2) 21 (1.2) 58 (1.7) 11 (1.4)

25–39 10 (0.6) 18 (0.6) 55 (0.9) 16 (0.9)

40–49 11 (0.9) 21 (0.9) 56 (1.2) 12 (1.0)

50–64 13 (0.9) 21 (0.7) 53 (1.1) 12 (0.9)

65+ 29 (1.4) 30 (0.8) 38 (1.3) 3 (0.5)

NOTE: Detail may not sum to totals because of rounding. Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table.

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

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

educational attainment: 2003

Educational attainment Average

Still in high school 241 (4.6)

Less than/some high school 184 (2.6)

GED/high school equivalency 232 (2.8)

High school graduate 232 (1.8)

Vocational/trade/business school 241 (2.9)

Some college 253 (1.6)

Associate’s/2-year degree 264 (2.3)

College graduate 280 (2.2)

Graduate studies/degree 287 (2.4)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
43

Appendix D: Standard Errors for Tables and Figures

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

threshold: 2003

Poverty threshold Average

Below poverty threshold 205 (2.6)

100–125% of poverty threshold 222 (3.0)

126–150% of poverty threshold 224 (3.6)

151–175% of poverty threshold 231 (3.1)

Above 175% of poverty threshold 261 (1.2)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table. Poverty thresholds are determined by the U.S. Census Bureau and are based on family income, family size, and the ages of family members.

Because adults provided their income in ranges rather than by precise dollar figures, adults could not be exactly matched to a federal poverty category.The categories shown in this table represent the best matches possible based on the categorical data.

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

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

highest educational attainment: 2003

Educational attainment Below Basic Basic Intermediate Proficient

Still in high school 13 (2.7) 24 (2.5) 56 (3.5) 7 (2.2)

Less than/some high school 49 (1.6) 27 (0.8) 23 (1.2) 1 (0.2)

GED/high school equivalency 14 (2.4) 30 (2.8) 54 (3.6) 3 (1.2)

High school graduate 15 (1.4) 29 (1.4) 53 (1.9) 4 (0.7)

Vocational/trade/business school 12 (1.8) 25 (2.1) 57 (2.7) 7 (1.6)

Some college 5 (0.9) 20 (1.6) 67 (2.0) 8 (1.4)

Associate’s/2-year degree 4 (0.9) 15 (1.7) 66 (2.2) 15 (2.3)

College graduate 3 (0.5) 10 (0.9) 60 (1.8) 27 (2.2)

Graduate studies/degree 3 (0.5) 8 (0.9) 57 (2.0) 33 (2.4)

NOTE: Detail may not sum to totals because of rounding. Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
44

The Health Literacy of America’s Adults

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

health insurance coverage: 2003

Type of health insurance Average

Employer provided 259 (1.2)

Military 248 (4.3)

Privately purchased 243 (2.3)

Medicare 216 (1.9)

Medicaid 212 (2.7)

No insurance 220 (2.4)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure. Adults who reported they had more than one type of health insurance are included in each applicable category in this table.

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

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

self-assessment of overall health: 2003

Self-assessment of overall health Below Basic Basic Intermediate Proficient

Excellent 8 (0.6) 17 (0.7) 57 (1.0) 19 (1.1)

Very good 9 (0.7) 19 (0.7) 59 (0.9) 13 (0.9)

Good 16 (1.1) 27 (0.9) 51 (1.3) 6 (0.7)

Fair 33 (1.7) 30 (1.0) 34 (1.6) 3 (0.5)

Poor 42 (2.3) 27 (1.3) 29 (1.8) 3 (0.6)

NOTE: Detail may not sum to totals because of rounding. Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table.

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

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

self-assessment of overall health: 2003

Self-assessment of overall health Average

Excellent 262 (1.8)

Very good 254 (1.4)

Good 234 (1.7)

Fair 207 (2.5)

Poor 196 (3.9)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 1992 National Adult Literacy Survey and 2003 National Assessment of Adult Literacy.
45

Appendix D: Standard Errors for Tables and Figures

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

type of health insurance coverage: 2003

Type of health insurance Below Basic Basic Intermediate Proficient

Employer provided 7 (0.5) 17 (0.6) 62 (0.9) 14 (0.9)

Military 12 (2.1) 21 (2.0) 56 (2.7) 11 (2.2)

Privately purchased 13 (1.2) 24 (1.2) 54 (1.6) 9 (1.2)

Medicare 27 (1.4) 30 (0.9) 40 (1.4) 3 (0.5)

Medicaid 30 (1.8) 30 (1.0) 38 (1.7) 3 (0.6)

No insurance 28 (1.3) 25 (0.6) 41 (1.1) 7 (0.5)

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

because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this figure. Adults who reported they had more than one type of health insurance are included in each applicable category in this table.

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

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

health issues from printed and written media: newspapers, magazines, books or brochures, and

the Internet, by health literacy level: 2003

Sources and literacy level None A little Some A lot

Newspapers

Below Basic 37 (1.6) 22 (1.4) 29 (1.5) 12 (1.0)

Basic 24 (0.9) 27 (0.9) 35 (1.0) 15 (0.8)

Intermediate 19 (0.7) 31 (0.7) 36 (0.8) 14 (0.5)

Proficient 20 (1.3) 38 (1.9) 32 (1.7) 10 (1.2)

Magazines

Below Basic 41 (1.7) 23 (1.4) 27 (1.5) 10 (1.0)

Basic 22 (0.8) 25 (0.9) 37 (1.1) 17 (0.9)

Intermediate 14 (0.6) 28 (0.7) 41 (0.8) 18 (0.7)

Proficient 12 (1.1) 35 (1.9) 40 (2.1) 12 (1.5)

Books or brochures

Below Basic 41 (1.6) 21 (1.3) 28 (1.5) 11 (0.9)

Basic 20 (0.8) 25 (0.9) 39 (1.1) 16 (0.8)

Intermediate 13 (0.5) 28 (0.7) 41 (0.8) 18 (0.6)

Proficient 11 (1.0) 35 (2.0) 36 (2.1) 18 (1.5)

Internet

Below Basic 80 (1.5) 5 (0.9) 7 (1.1) 7 (0.8)

Basic 58 (1.5) 12 (1.0) 16 (1.2) 14 (0.8)

Intermediate 33 (1.1) 19 (0.7) 27 (0.9) 21 (0.6)

Proficient 15 (1.5) 22 (2.4) 37 (2.7) 26 (2.1)

NOTE: Detail may not sum to totals because of rounding. Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table. Prison inmates are not included in the Internet category because they do not have access to

the Internet.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
46

The Health Literacy of America’s Adults

Table D3-7. Estimates and standard errors for Figure 3-7. Percentage of adults who got information about

health issues from personal contacts: family, friends, or coworkers; or health care professionals, by

health literacy level: 2003

Sources and literacy level None A little Some A lot

Family, friends, or coworkers

Below Basic 24 (1.4) 23 (1.4) 35 (1.7) 19 (1.3)

Basic 15 (0.7) 25 (0.9) 40 (1.0) 20 (0.8)

Intermediate 9 (0.4) 28 (0.7) 44 (0.8) 19 (0.6)

Proficient 5 (0.6) 31 (2.0) 48 (2.0) 17 (1.4)

Health care professionals

Below Basic 18 (1.1) 17 (1.2) 29 (1.6) 36 (1.6)

Basic 11 (0.5) 19 (0.8) 33 (1.1) 37 (1.1)

Intermediate 8 (0.4) 21 (0.6) 37 (0.8) 34 (0.9)

Proficient 8 (0.7) 23 (1.7) 39 (2.1) 30 (1.7)

NOTE: Detail may not sum to totals because of rounding. Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table. Adults living in households were asked about getting information from “family members,

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

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

Table D3-6. Estimates and standard errors for Figure 3-6. Percentage of adults who got information about

health issues from nonprint media: radio and television, by health literacy level: 2003

Literacy level None A little Some A lot

Below Basic 14 (0.9) 19 (1.3) 34 (1.7) 33 (1.8)

Basic 8 (0.4) 21 (0.9) 40 (1.1) 31 (1.1)

Intermediate 7 (0.3) 24 (0.7) 44 (0.8) 25 (0.8)

Proficient 9 (0.8) 30 (1.8) 43 (2.0) 17 (1.6)

NOTE: Detail may not sum to totals because of rounding. Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 1992 National Adult Literacy Survey and 2003 National Assessment of Adult Literacy.
Additional Analyses

47

APPENDIX E 

E
Health Literacy by Occupation

Health Literacy by Self-Assessment of Overall Health

48

The Health Literacy of America’s Adults

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

Occupational group Average

Management, business, and financial 275 (3.1)

Professional and related 281 (1.8)

Service 233 (2.5)

Sales and related 253 (2.7)

Office and administrative support 255 (2.1)

Farming, fishing, and forestry 191 (11.6)

Construction and extraction 228 (3.6)

Installation, maintenance, and repair 244 (3.6)

Production 228 (2.9)

Transportation and material moving 226 (2.9)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

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

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

Self-assessment of overall health Men Women

Poor 186 (6.4) 205 (5.4)

Fair 204 (3.4) 210 (3.0)

Good 232 (2.7) 235 (1.8)

Very good 251 (2.0) 257 (1.9)

Excellent 257 (2.6) 267 (2.6)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
Table E-4. Average health literacy scores of adults, by self-assessment of overall health and age: 2003

Self-assessment of overall health 16–24 25–39 40–49 50–64 65+

Poor — 227 (14.2) 189 (7.4) 201 (7.3) 179 (8.6)

Fair 226 (8.1) 207 (6.0) 214 (6.0) 215 (4.8) 192 (3.8)

Good 235 (4.8) 243 (2.8) 238 (3.1) 238 (3.0) 213 (3.2)

Very good 252 (3.0) 262 (2.9) 257 (2.7) 255 (3.2) 232 (4.0)

Excellent 252 (3.7) 268 (2.8) 266 (3.8) 273 (4.0) 231 (6.4)

—Not available due to small sample size.

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

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

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

attainment: 2003

Less than/ High school graduate/GED/ College graduate/

Self-assessment of overall health some high school high school equivalency At least some college graduate studies/degree

Poor 155 (5.6) 207 (6.3) 234 (9.6) 217 (22.8)

Fair 168 (4.3) 211 (3.0) 233 (4.4) 256 (6.5)

Good 185 (3.9) 226 (2.3) 246 (2.6) 273 (3.9)

Very good 202 (3.4) 242 (2.4) 261 (2.2) 285 (3.4)

Excellent 189 (3.6) 241 (3.8) 262 (2.3) 291 (2.9)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

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

49

Appendix E: Additional Analyses

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

Self-assessment of overall health White Black Hispanic Other

Poor 206 (5.2) 175 (6.6) 157 (9.2) 179 (17.2)

Fair 219 (3.0) 193 (4.1) 155 (6.4) 210 (5.4)

Good 242 (2.1) 216 (2.6) 187 (5.1) 244 (5.8)

Very good 264 (1.7) 225 (2.6) 211 (4.1) 254 (7.8)

Excellent 274 (2.1) 223 (3.2) 212 (4.2) 259 (8.5)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.The “Other” category includes Asians, Pacific Islanders, Native Hawaiians, American Indians, Alaska Natives, and multiracial adults. All adults of

Hispanic origin are classified as Hispanic, regardless of race.

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

50

The Health Literacy of America’s Adults

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

Type of health insurance Men Women

Employer provided 255 (1.4) 262 (1.7)

Military 243 (5.0) 258 (5.3)

Privately purchased 244 (4.0) 241 (2.6)

Medicare 215 (3.1) 217 (2.3)

Medicaid 201 (5.1) 217 (2.7)

No insurance 216 (3.1) 224 (3.1)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table. Adults who reported they had more than one type of health insurance are included in each applicable category in this table.

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

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

2003

Type of health insurance White Black Hispanic Other

Employer provided 266 (1.4) 226 (2.5) 229 (2.6) 258 (4.4)

Military 255 (5.1) 224 (6.8) 225 (10.1) —

Privately purchased 246 (2.4) 212 (4.3) 224 (8.8) 243 (9.0)

Medicare 222 (2.2) 178 (5.3) 161 (7.6) —

Medicaid 224 (4.4) 202 (3.1) 181 (4.7) 228 (10.2)

No insurance 241 (2.5) 212 (2.8) 170 (5.2) 229 (10.6)

—Not available due to small sample size.

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table. All adults of Hispanic origin are classified as Hispanic, regardless of race. Adults who reported they had more than one type of health insurance are included in each applicable category in this table.

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

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

Type of health insurance 16–24 25–39 40–49 50–64 65+

Employer provided 258 (3.1) 269 (1.7) 259 (2.0) 257 (2.3) 231 (3.3)

Military 262 (11.9) 277 (5.1) 271 (12.5) 240 (6.1) 224 (8.2)

Privately purchased 261 (8.2) 266 (6.5) 263 (8.1) 252 (4.1) 219 (3.4)

Medicare — 239 (11.1) 220 (6.4) 214 (6.5) 216 (2.1)

Medicaid 224 (4.2) 229 (4.0) 201 (5.6) 192 (5.8) 185 (8.0)

No insurance 227 (3.9) 221 (3.1) 224 (4.9) 207 (5.1) 169 (9.5)

—Not available due to small sample size.

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table. Adults who reported they had more than one type of health insurance are included in each applicable category in this table.

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

Printed and Written Information

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

magazines, and books or brochures, by gender: 2003

Source and amount of information Men Women

Newspapers

None 228 (3.2) 232 (2.5)

A little 249 (2.3) 258 (2.4)

Some 245 (1.6) 248 (1.8)

A lot 241 (3.3) 245 (2.3)

Magazines

None 219 (2.9) 214 (3.6)

A little 250 (2.3) 254 (2.7)

Some 249 (2.2) 252 (1.7)

A lot 243 (2.7) 251 (1.9)

Books or brochures

None 218 (3.0) 208 (3.7)

A little 252 (2.0) 253 (2.8)

Some 245 (1.8) 251 (1.9)

A lot 246 (2.5) 255 (2.2)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

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

51

Appendix E: Additional Analyses

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

educational attainment: 2003

Less than/ High school graduate/GED/ College graduate/

Type of health insurance some high school high school equivalency At least some college graduate studies/degree

Employer provided 205 (3.5) 241 (2.0) 261 (1.5) 288 (1.9)

Military 206 (13.5) 233 (8.5) 257 (6.7) 272 (9.3)

Privately purchased 193 (6.2) 228 (3.1) 253 (4.0) 272 (4.6)

Medicare 171 (4.5) 215 (2.5) 229 (3.4) 251 (4.5)

Medicaid 177 (4.9) 221 (3.5) 237 (4.0) 247 (13.4)

No insurance 171 (4.5) 223 (2.9) 246 (3.0) 262 (7.4)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households. Adults who could not be interviewed because of language spoken or cognitive or mental disabilities (3 percent in 2003) are excluded from this table. Adults who reported they had more than one type of health insurance are included in each applicable category in this table.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
Table E-12. Average health literacy scores of adults who got information about health issues from newspapers,

magazines, and books or brochures, by race/ethnicity: 2003

Source and amount of information White Black Hispanic Other

Newspapers

None 246 (2.4) 202 (3.8) 172 (5.1) 242 (8.1)

A little 264 (2.0) 222 (2.9) 203 (5.4) 248 (6.5)

Some 255 (1.8) 220 (2.1) 213 (2.8) 249 (7.5)

A lot 253 (2.6) 216 (4.1) 207 (5.9) 240 (9.1)

Magazines

None 234 (2.8) 193 (3.5) 163 (5.7) 218 (12.5)

A little 262 (2.2) 219 (3.1) 197 (4.9) 247 (6.9)

Some 259 (1.8) 222 (2.3) 215 (3.3) 255 (6.0)

A lot 258 (2.2) 223 (3.6) 221 (5.6) 241 (8.2)

Books or brochures

None 231 (3.0) 188 (5.9) 159 (5.6) 225 (15.0)

A little 262 (2.0) 219 (3.0) 202 (5.8) 245 (5.8)

Some 257 (1.9) 221 (2.5) 212 (3.4) 249 (7.3)

A lot 262 (2.3) 222 (3.6) 225 (4.2) 257 (7.5)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.The “Other” category includes Asians, Pacific Islanders, Native Hawaiians, American Indians, Alaska Natives, and multiracial adults. All adults of

Hispanic origin are classified as Hispanic, regardless of race.

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

52

The Health Literacy of America’s Adults

Table E-11. Average health literacy scores of adults who got information about health issues from the Internet,

by gender: 2003

Amount of information from the Internet Men Women

None 213 (1.8) 220 (1.9)

A little 259 (2.9) 267 (2.8)

Some 265 (2.4) 266 (2.0)

A lot 264 (2.8) 262 (2.1)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

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

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
53

Appendix E: Additional Analyses

Table E-13. Average health literacy scores of adults who got information about health issues from the Internet,

by race/ethnicity: 2003

Amount of information from the Internet White Black Hispanic Other

None 229 (1.5) 198 (2.7) 162 (4.0) 221 (9.4)

A little 270 (2.6) 230 (3.9) 239 (5.2) 255 (8.9)

Some 273 (2.1) 232 (3.3) 234 (3.7) 268 (7.9)

A lot 272 (2.1) 234 (3.0) 235 (4.0) 249 (6.3)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.The “Other” category includes Asians, Pacific Islanders, Native Hawaiians, American Indians, Alaska Natives, and multiracial adults. All adults of

Hispanic origin are classified as Hispanic, regardless of race. Prison inmates are not included in the Internet category because they do not have access to the Internet.

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

Table E-14. Average health literacy scores of adults who got information about health issues from newspapers,

magazines, and books or brochures, by age: 2003

Source and amount of information 16–24 25–39 40–49 50–64 65+

Newspapers

None 241 (4.2) 245 (3.0) 229 (4.4) 217 (3.6) 182 (5.7)

A little 256 (3.7) 267 (2.5) 260 (3.5) 250 (3.5) 208 (3.8)

Some 243 (3.2) 256 (2.4) 251 (2.6) 252 (3.5) 222 (2.7)

A lot 243 (5.8) 242 (4.2) 247 (4.3) 254 (4.2) 227 (4.9)

Magazines

None 236 (4.5) 232 (3.9) 218 (4.3) 207 (4.8) 171 (4.5)

A little 247 (3.4) 263 (2.9) 260 (3.6) 251 (4.6) 213 (4.6)

Some 253 (3.6) 259 (2.2) 254 (2.6) 253 (3.1) 227 (2.6)

A lot 252 (3.5) 261 (3.6) 248 (3.7) 251 (4.1) 223 (3.6)

Books or brochures

None 236 (4.6) 222 (3.4) 221 (6.0) 198 (4.8) 172 (5.1)

A little 254 (4.0) 265 (3.1) 248 (4.0) 253 (4.6) 217 (4.0)

Some 246 (3.5) 258 (2.4) 254 (2.9) 252 (2.7) 223 (2.3)

A lot 253 (5.7) 266 (3.4) 255 (4.6) 249 (3.7) 228 (4.3)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
54

The Health Literacy of America’s Adults

Table E-16. Average health literacy scores of adults who got information about health issues from newspapers,

magazines, and books or brochures, by highest educational attainment: 2003

Less than/ High school graduate/GED/ College graduate/

Source and amount of information some high school high school equivalency At least some college graduate studies/degree

Newspapers

None 167 (4.5) 228 (2.3) 252 (2.2) 280 (5.2)

A little 192 (4.0) 238 (2.9) 262 (2.4) 289 (3.2)

Some 195 (3.0) 230 (2.2) 255 (1.9) 281 (3.0)

A lot 191 (3.7) 229 (3.7) 245 (3.5) 281 (4.6)

Magazines

None 160 (3.4) 223 (2.7) 244 (3.3) 273 (6.2)

A little 194 (4.2) 237 (3.0) 261 (2.3) 289 (3.8)

Some 196 (3.3) 234 (2.2) 256 (1.8) 283 (2.7)

A lot 203 (3.8) 229 (3.0) 253 (2.9) 280 (3.1)

Books or brochures

None 162 (3.6) 221 (2.6) 241 (4.1) 267 (7.2)

A little 194 (4.7) 239 (3.2) 258 (1.6) 289 (3.3)

Some 194 (3.2) 232 (2.2) 256 (2.2) 284 (3.0)

A lot 204 (3.6) 232 (3.3) 258 (2.9) 281 (3.7)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

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

Table E-15. Average health literacy scores of adults who got information about health issues from the Internet,

by age: 2003

Amount of information from the Internet 16–24 25–39 40–49 50–64 65+

None 224 (4.3) 222 (3.2) 218 (2.4) 222 (2.5) 203 (2.2)

A little 257 (3.7) 262 (3.4) 272 (5.0) 270 (4.7) 249 (7.5)

Some 257 (3.8) 274 (3.2) 266 (2.9) 266 (3.7) 250 (5.1)

A lot 255 (4.0) 274 (2.7) 262 (4.1) 260 (4.5) 235 (6.1)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

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

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

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

by highest educational attainment: 2003

Amount of information Less than/ High school graduate/GED/ College graduate/

from the Internet some high school high school equivalency At least some college graduate studies/degree

None 172 (2.7) 220 (1.5) 237 (2.2) 258 (3.0)

A little 217 (5.7) 253 (4.0) 260 (2.7) 289 (4.1)

Some 210 (4.6) 244 (3.0) 266 (2.9) 291 (2.9)

A lot 221 (5.6) 244 (4.2) 264 (2.3) 288 (3.5)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

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

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

55

Appendix E: Additional Analyses

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

television, by gender: 2003

Amount of information 

from radio and television Men Women

None 237 (4.6) 234 (4.6)

A little 249 (2.5) 256 (2.8)

Some 247 (1.8) 251 (1.9)

A lot 229 (2.3) 239 (2.8)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

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

Table E-19. Average health literacy scores of adults who got information about health issues from radio and 

television, by race/ethnicity: 2003

Amount of information 

from radio and television White Black Hispanic Other

None 249 (3.8) 202 (5.4) 195 (6.3) 223 (11.9)

A little 262 (2.2) 220 (3.8) 203 (5.8) 243 (7.3)

Some 258 (1.8) 219 (2.5) 202 (4.1) 257 (6.4)

A lot 247 (2.0) 214 (3.5) 187 (4.9) 239 (5.9)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.The “Other” category includes Asians, Pacific Islanders, Native Hawaiians, American Indians, Alaska Natives, and multiracial adults. All adults of

Hispanic origin are classified as Hispanic, regardless of race.

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

Table E-20. Average health literacy scores of adults who got information about health issues from radio and 

television, by age: 2003

Amount of information 

from radio and television 16–24 25–39 40–49 50–64 65+

None 246 (6.4) 252 (6.3) 245 (6.2) 223 (5.9) 192 (6.9)

A little 248 (4.4) 265 (3.9) 258 (3.6) 254 (4.1) 223 (4.7)

Some 252 (3.6) 257 (2.3) 253 (2.9) 253 (2.7) 219 (2.7)

A lot 240 (3.7) 246 (3.0) 237 (3.3) 231 (3.0) 204 (3.5)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

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

56

The Health Literacy of America’s Adults

Table E-21. Average health literacy scores of adults who got information about health issues from radio and 

television, by highest educational attainment: 2003

Amount of information Less than/ High school graduate/GED/ College graduate/

from radio and television some high school high school equivalency At least some college graduate studies/degree

None 172 (5.5) 219 (5.2) 256 (4.4) 282 (7.7)

A little 186 (5.1) 238 (3.0) 258 (2.6) 289 (2.9)

Some 187 (3.3) 235 (2.1) 257 (1.9) 283 (2.7)

A lot 183 (3.4) 227 (2.9) 250 (2.9) 277 (4.8)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

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

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

friends, or coworkers, by gender: 2003

Amount of information from 

family, friends, or coworkers Men Women

None 215 (3.3) 217 (3.0)

A little 249 (2.2) 251 (2.6)

Some 246 (2.0) 253 (1.8)

A lot 240 (2.5) 245 (2.3)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

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

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

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

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

professionals, by gender: 2003

Amount of information from 

health care professionals Men Women

None 228 (3.6) 223 (4.4)

A little 249 (2.5) 252 (2.9)

Some 248 (2.3) 251 (2.3)

A lot 236 (1.7) 245 (1.8)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
57

Appendix E: Additional Analyses

Table E-24. Average health literacy scores of adults who got information about health issues from family,

friends, or coworkers, by race/ethnicity: 2003

Amount of information from 

family, friends, or coworkers White Black Hispanic Other

None 229 (2.8) 200 (4.9) 170 (5.3) 219 (11.6)

A little 260 (2.5) 224 (3.2) 201 (4.5) 243 (7.3)

Some 259 (1.6) 220 (3.1) 203 (4.3) 257 (7.1)

A lot 255 (2.3) 212 (2.7) 198 (6.2) 244 (6.5)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.”The “Other” category includes Asians, Pacific Islanders, Native Hawaiians, American Indians, Alaska Natives, and multiracial adults. All adults of

Hispanic origin are classified as Hispanic, regardless of race. Adults living in households were asked about getting information from “family members, friends, or coworkers”; prison inmates were asked about getting information from “family members, friends, other inmates, or staff.”

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

Table E-25. Average health literacy scores of adults who got information about health issues from health care

professionals, by race/ethnicity: 2003

Amount of information from

health care professionals White Black Hispanic Other

None 246 (3.4) 208 (3.2) 172 (5.7) 231 (10.2)

A little 260 (2.2) 221 (3.9) 196 (4.7) 252 (10.0)

Some 259 (2.1) 220 (2.7) 199 (4.1) 252 (7.7)

A lot 252 (1.6) 215 (2.9) 209 (5.0) 240 (5.2)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.The “Other” category includes Asians, Pacific Islanders, Native Hawaiians, American Indians, Alaska Natives, and multiracial adults. All adults of

Hispanic origin are classified as Hispanic, regardless of race.

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

Table E-26. Average health literacy scores of adults who got information about health issues from family,

friends, or coworkers, by age: 2003

Amount of information from 

family, friends, or coworkers 16–24 25–39 40–49 50–64 65+

None 218 (5.5) 227 (5.6) 229 (5.4) 219 (4.3) 197 (3.4)

A little 252 (4.6) 258 (3.7) 255 (3.3) 252 (3.4) 222 (4.5)

Some 251 (3.0) 261 (2.3) 252 (2.6) 250 (3.2) 219 (3.0)

A lot 246 (3.3) 253 (3.3) 239 (4.6) 242 (4.4) 209 (5.1)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

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

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

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
58

The Health Literacy of America’s Adults

Table E-27. Average health literacy scores of adults who got information about health issues from health care

professionals, by age: 2003

Amount of information from 

health care professionals 16–24 25–39 40–49 50–64 65+

None 239 (5.1) 230 (4.5) 230 (5.7) 221 (6.4) 178 (6.6)

A little 255 (4.2) 254 (2.9) 251 (3.7) 256 (4.8) 213 (5.8)

Some 249 (4.1) 263 (2.9) 253 (3.0) 253 (3.8) 218 (3.0)

A lot 242 (3.0) 258 (2.3) 247 (2.5) 238 (3.3) 216 (2.3)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

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

Table E-28. Average health literacy scores of adults who got information about health issues from family,

friends, or coworkers, by highest educational attainment: 2003

Amount of information from Less than/ High school graduate/GED/ College graduate/

family, friends, or coworkers some high school high school equivalency At least some college graduate studies/degree

None 166 (3.7) 214 (3.1) 239 (4.2) 255 (4.7)

A little 184 (4.0) 235 (2.5) 258 (2.2) 288 (3.8)

Some 190 (3.8) 235 (2.6) 257 (1.8) 287 (2.6)

A lot 188 (4.8) 233 (2.7) 254 (3.0) 282 (4.2)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

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

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

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

Table E-29. Average health literacy scores of adults who got information about health issues from health care

professionals, by highest educational attainment: 2003

Amount of information from Less than/ High school graduate/GED/ College graduate/

health care professionals some high school high school equivalency At least some college graduate studies/degree

None 167 (5.2) 225 (4.4) 251 (4.6) 280 (9.0)

A little 185 (5.3) 243 (3.5) 258 (2.6) 284 (3.4)

Some 184 (3.7) 234 (2.2) 259 (1.7) 285 (2.7)

A lot 190 (3.6) 226 (2.3) 251 (2.1) 283 (2.7)

NOTE: Standard errors are in parentheses. Adults are defined as people 16 years of age and older living in households or prisons.Adults who could not be interviewed because of language spoken or cognitive or

mental disabilities (3 percent in 2003) are excluded from this table.

SOURCE: U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy.
59

toc

CHAPTER ONE REFERENCES

1

References

Baker, D.W., Gazmararian, J.A., Williams, M.V., Scott, T.,

Parker, R.M., Green, D., Ren, J., and Peel, J. (2004).

Health Literacy and Use of Outpatient Physician

Services by Medicare Managed Care Enrollees.

Journal of General Internal Medicine, 19(3): 215–220.

Baker, D.W., Parker, R.M.,Williams, M.V., and Clark,W.S.

(1998). Health Literacy and the Risk of Hospitalization.

Journal of General Internal Medicine, 13(12): 791–798.

Berkman, N.D., DeWalt, D.A., Pignone, M.P., Sheridan,

S.L., Lohr, K.N., Lux, L., Sutton, S.F., Swinson, T.,

Bonito, A.J. (2004) Literacy and Health Outcomes.

Evidence Report/Technology Assessment No. 87

(Prepared by RTI International—University of North

Carolina Evidence-based Practice Center under

Contract No. 290-02-0016). AHRQ Publication No.

04-E007-2. Rockville, MD: Agency for Healthcare

Research and Quality.

Binder, D.A. (1983). On the Variances of Asymptotically

Normal Estimates for Complex Surveys. International

Statistical Review, 51(3): 279–292.

Fox, S., and Rainie, L. (2000). The Online Health Care

Revolution: How the Web Helps Americans Take Better Care

of Themselves. Washington, DC: Pew Charitable Trusts.

Gordon, M.M., Hampson, R., Capell, H.A., and Madhok,

R. (2002). Illiteracy in Rheumatoid Arthritis Patients as

Determined by the Rapid Estimate of Adult Literacy in

Medicine (REALM) Score. Rheumatology (Oxford),

41(7): 750–754.
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The Health Literacy of America’s Adults

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