and western regions of the United States, those with less than a high school degree or GED, and those who are above the age of 65. It is important to keep in mind that the NALS was performed only in English, and that clear differentials for literacy proficiencies can be seen within each population group on the basis of nativity, education, and access to economic resources (Kirsch et al., 1993). Table 3-1 displays the percentage of persons overall and various demographic groups that have NALS Level 1 or 2 literacy skills, the lowest of five skill levels. Each of these groups is discussed briefly below in order to highlight those that could potentially benefit from interventions aimed at improving health literacy.3

Adults over the age of 65 have more limited literacy proficiency than younger, working adults, according to the NALS data. However, cross-tabulations indicate that scores for elders vary by education level and access to financial resources (Kirsch et al., 1993). Hispanics, African Americans, Pacific Islanders, and Native Americans are also (including Alaska Natives) over-represented in the numbers of adults with lower literacy proficiency scores, as indicated by the NALS data (Kirsch et al., 1993). These populations have increased in number since 1992, when the NALS was performed, and as a group represent a larger proportion of the U.S. population (U.S. Census Bureau, 2002). Hispanic and Asian populations in particular have increased at a greater rate than other U.S. populations. While more recent literacy data is not yet available, these population increases may represent an increase in the number of individuals, and the percentage of American adults, affected by limited health literacy.

Individuals without a high school diploma or GED have lower levels of literacy proficiency than do those with a high school diploma or education beyond high school. Nearly all adults who did not finish eighth grade scored at Level 1 or 2 on the NALS, and 77 percent of these individuals scored at Level 1. Similarly, among individuals who entered high school but did not graduate, 81 percent scored at NALS Levels 1 or 2, while only 55 percent of high school graduates scored at those levels (Kirsch et al., 1993). Since between 400,000 and 500,000 students drop out of high school each year in the United States (Young, 2002), high school dropouts constitute a large population likely living without adequate literacy skills.

Overall, more than 70 percent of immigrants tested on the NALS scored at Levels 1 or 2. The NALS was conducted in English only. Thus the finding that 25 percent of those scoring in the lowest levels of literacy proficiency were immigrants to the United States might be expected, since many of


The information in this section is drawn in part from the background paper “Outside the Clinician-Patient Relationship: A Call to Action For Health Literacy,” commissioned by the committee from Barry D. Weiss, M.D. The committee appreciates his contributions. The full text of the paper can be found in Appendix B.

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