Press Releases

2004 Releases

Study Measures Literacy Skills Critical to Good Health

For immediate release: May 05, 2004  

Boston, MA and Princeton, NJ -- With billions of dollars being spent every year on health care, a new study from Educational Testing Service (ETS) and Harvard School of Public Health identifies, for the first time, the health-related literacy skills of U.S. adults and finds marked differences among adults based on their education, age, wealth and country of birth.

The authors of the study argue that literacy is one of the major factors linking health and education and contributes to existing disparities in health status, access to care and the quality of health care for many individuals. The study provides a benchmark for tracking changes in health-related literacy following possible education efforts and improvements in health care communication.

"We can only make improvements in health literacy if we pay attention to how people are expected to use health materials, not just to the way the materials are written," said Rima Rudd, one of the co-authors and a member of the faculty of Harvard School of Public Health.

The report, Literacy and Health in America, is the third in a series of reports using information collected from existing surveys, the National Adult Literacy Survey (NALS) and the International Adult Literacy Survey (IALS), conducted by ETS for the U.S. Department of Education.  For the first time, the authors, Rima Rudd of Harvard School of Public Health, and Irwin Kirsch and Kentaro Yamamoto of ETS, identified 191 health-related tasks among the survey data and created a Health Activities Literacy Scale (HALS), a 0 to 500 scale that reflects a progression of five levels of health literacy.

The most health-literate populations, comprising about half of adults, were those who are more well-to-do and have more than a high school education. They also report using the library; they vote and they tend to be healthier as a group.

The researchers found that some 12 percent or 23 million of U.S. adults are estimated to have skills in the lowest level (Level 1) on the HALS, while an additional 7 percent or 13.4 million are not able to perform even simple health literacy tasks with a high degree of proficiency (below Level 1).  Those performing below Level 1 are about evenly divided between U.S.-born and foreign-born adults. 

Results are alarming for at-risk and vulnerable populations. For example, among adults who have not completed high school, almost half scored at or below the lowest literacy level. Similarly, almost half of adults over the age of 65 performed at or below the lowest level. Minority populations, including adults born outside the United States, scored significantly below white adults and adults born in the United States, on average.

"Each day, millions of adults must make decisions, take actions, and consider issues that influence not only their own well-being but that of their family members and of their community," writes Rudd. "These actions are not solely confined to traditional healthcare settings. They take place in homes, at work, and in communities across the country.

This study has systematically examined tasks in everyday settings. These include how well people use package labels found on household goods, appliances, cleaning products, or even over-the-counter medicines. "There is a mismatch," said Rudd. "We misjudge people's skills on one hand and write very difficult materials on the other hand, not thinking about how people need to use the materials."

Kirsch, of ETS's Center for Global Assessment, pointed out that "health researchers would benefit from a rigorous measure of health literacy that goes beyond word recognition or reading comprehension to differentiate between understanding prose and understanding documents, to examine oral comprehension and numerical skills."

 "The health-related tasks used in this analysis range from simple to complex and represent tasks undertaken in each of five health contexts," explained Yamamoto, principal research scientist in ETS's Center for Global Assessment.  "This study provides a national benchmark for looking at health literacy and for examining changes over time, within multiple health contexts, and for a variety of health-related tasks."

Download Literacy and Health in America for free at Purchase copies for $15.00 (prepaid) by writing to the Policy Information Center, ETS, MS 19-R, Rosedale Road, Princeton, NJ 08541-0001; by calling 609-734-5694; or by sending an e-mail to

For further information contact:
Robin Herman
Director of Communications
Harvard School of Public Health

Tom Ewing
Educational Testing Service (ETS)

About ETS

Founded in 1947, ETS is the world's largest private, nonprofit educational testing and measurement organization and a leader in education research. ETS products and services measure knowledge and skills, promote learning and performance, and support education and professional development. ETS's 2,700 employees produce and administer nearly 12 million tests annually in more than 180 countries. ETS is dedicated to serving the needs of individuals, educational institutions, and government agencies around the world. ETS is located on the Web at

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