FIGURE 3-1 Mock-up prescription medication instructions in Bahasa Malaysia, the written language of Malaysia.

SOURCE: Shinagawa and Foong (2003). Reprinted with permission.

and use for everyday activities, but will often face problems with unfamiliar types of text. For example, a woman who has never lived near a public transportation system may find herself unable to interpret a bus schedule. Directions for operating a particle accelerator, filing income tax returns, or choosing between health insurance plans may be similarly indecipherable for most adults, regardless of literacy skills in other contexts.

As discussed in detail in Chapter 2, current measures of health literacy rely primarily on print in the health context and not on the broad array of skills needed for true health literacy. However, since skills with the written word are linked to skills with the spoken word, we can use information from these measures as a starting point to make reasonable assumptions about the average health literacy skill level of adults in the United States. The following section examines the extent of the problem of health literacy, estimated from existing measures of literacy based on the National Adult Literacy Survey (NALS) and from assessments of health literacy.


About 90 million (47 percent) U.S. adults cannot accurately and consistently locate, match, and integrate information from newspapers, advertisements, or forms (Kirsch et al., 1993). These adults can perform a variety of

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