the numbers and operations are found in familiar and uncomplicated materials. However, adults at Level 2 find it difficult to perform these operations in difficult text and to perform operations that are complicated by distracting information and complex texts (Morse, 2002). In addition, they will find the demands of the chart to determine dosage for children’s cold medicine difficult and, according to studies assessing informed consent documents, will find the process of informed consent arduous and most likely not possible.

Most of the adults in NALS Levels 1 and 2 are “literate”; however, adults in Level 1 are at a severe disadvantage and adults in Level 2 are disadvantaged, in relation to the demands of twenty-first century life. These findings have serious implications for the health sectors. Rudd, Kirsch, and Yamamoto, in a reanalysis of the NALS with a focus on health-related tasks only, report similar findings (Rudd et al., 2003). The 1992 NALS survey provides the most recent nationally representative population survey data on literacy skills of adults in the United States. The committee believes that levels of American literacy have not improved over the past decade and that health systems have become more complex. The committee looks forward to the publication of the National Assessment of Adult Literacy1 (NAAL), conducted in 2003, which contains health-related literacy tasks. The committee believes that the NAAL will significantly expand our understanding of literacy and health literacy in America, and regrets that the data are not yet available. In addition, a representative sample of American adults is included in the new international Adult Literacy & Lifeskills Survey (ALL).2 Linked to the NAAL framework, the ALL also contains health-related literacy tasks. These two surveys have the potential to provide detailed information on the extent of limited health literacy in America.

Demographic Associations with Limited Literacy

The largest proportion of American adults with limited literacy are native-born Caucasian speakers of English. Over half of the people with NALS Level 1 skills are Caucasians, and about 57 million Caucasian Americans have limited literacy skills (NALS Levels 1 and 2) (Kirsch et al., 1993). However, many groups with higher rates of limited literacy than would be predicted from population estimates alone were identified by the NALS. Groups with lower average proficiency scores include those who are poor, members of ethnic and cultural minorities, those who live in the southern


For more information, see the NAAL on the National Center for Education Statistics web site:


For more information, see ALL on the Educational Testing Service web site:

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