LITERACY in Canada INITIAL RESULTS from the International Adult Literacy and Skills Survey
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This publication has been prepared by Scott Murray, Data Angel Policy Research Incorporated, Rima Rudd, Harvard School of Public Health, Irwin Kirsch, Educational Testing Service, Kentaro Yamamoto, Educational Testing Service and Sylvie Grenier, Statistics Canada.
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Cite this publication in the following format: Health Literacy in Canada: Initial results from the International Adult Literacy and Skills Survey 2007 (Ottawa: 2007). page(s).
Published in September 2007. Ottawa, Ontario ISBN 978-0-9783880-1-0 Aussi disponible en français sous Littératie en santé au Canada : Résultats initiaux de l’Enquête internationale sur l’alphabétisation et les compétences des adultes, 2007 The Canadian Council on Learning is an independent, not-for-profit corporation funded through an agreement with Human Resources and Social Development Canada. Its mandate is to promote and support evidence-based decisions about learning throughout all stages of life, from early childhood through to the senior years.
table of contents EXECUTIVE SUMMARY................................................................3 What is health literacy?................................................ 3 Why does health literacy matter?................................ 3 How has our understanding of health literacy changed?.......................................... 4 How has the analytical framework for health literacy changed?........................................ 4 What is the current state of thinking in regard to measuring health literacy?....................... 5
CHAPTER 4—MEASURES OF HEALTH LITERACY...................16 HEALTH ACTIVITIES......................................................... 17 A FRAMEWORK FOR UNDERSTANDING HEALTH LITERACY........................... 17 Health Promotion....................................................... 17
What do the initial analyses of the health-literacy scales for Canada reveal?............................................ 5
Health Protection....................................................... 17
What are some of the public policy issues flowing from this report?............................................. 6
Health Care................................................................ 18
What are the next steps?............................................. 6
CODING THE LITERACY ITEMS...................................... 19
CHAPTER 1—THE GENESIS OF HEALTH LITERACY.................7
CHAPTER 5—THE DISTRIBUTION OF HEALTH LITERACY IN CANADA..................20
CHAPTER 2—THE FIELD OF HEALTH LITERACY.......................9
CHAPTER 6—SUMMARY AND CONCLUSIONS......................24
Disease Prevention.................................................... 18 Navigation.................................................................. 18
IMPLICATIONS FOR POLICY........................................... 25 CHAPTER 3—MEASURING PROFICIENCIES OF ADULTS.......12
IMPLICATIONS FOR FURTHER RESEARCH..................... 26
MEASURES OF ADULT LITERACY................................... 12 DEFINITION AND FRAMEWORK.................................... 13 CONTEXTS, TEXTS, AND TASKS.................................... 14
ANNEX A—METHODOLOGICAL APPROACH TO CREATING THE HALS......................................27
PROFICIENCY SCORES................................................... 15
executive summary The primary goal of this paper is to report on the distribution of health literacy among the Canadian adult population and to report on the public policy implications that flow from this information. The paper is based on a review of the 2003 Adult Literacy and Skills Survey, the 2004 report Literacy and Health in America and a forthcoming report by Canadian and American researchers that compares and contrasts the distribution of adult health literacy in Canada and the United States.
What is health literacy?
Why does health literacy matter?
Health literacy generally refers to the ability of individuals to access and use health information to make appropriate health decisions and maintain basic health. For health and education researchers, the concept is a broad one. It includes whether individuals can read and act upon written health information, as well as whether they possess the speaking skills to communicate their health needs to physicians and the listening skills to understand and act on the instructions they receive.
Studies over the years have repeatedly demÂ onstrated a strong link among literacy, level of education and level of health. Health and learning are closely intertwined and the interaction between them is evident at all ages, from early childhood through to the later stages in life. The equation is a simple one: the higher a personâ€™s education status and ability to learn about health, the better that personâ€™s health. Researchers and policy-makers in the health and education fields consider health literacy as a critical pathway linking education to health outcomes, as a
LITERACY in Canada
• Finally, new research efforts are focussing on numeracy, listening and speaking skills of health providers and their patients—skills that are essential to effective public health communication and dialogue.
causal factor in health disparities between different population groups and as a predictor of overall population health.
How has our understanding of health literacy changed?
How has the analytical framework for health literacy changed?
A series of groundbreaking reports in the late 1980s in both Canada and the United States established a link between education and health outcomes. These reports also galvanized the interest of Canadian education and health researchers, inspiring them to study this important field. By 1994, the Canadian Public Health Association established the National Literacy and Health Program through which it has worked with a network of partners in the health and literacy fields to establish a firm foundation for health literacy as an area of inquiry.
Throughout the 1980s and 1990s, advances in a variety of disciplines across the social sciences enabled researchers to acquire new insights into ways of measuring and comparing adult skill levels within and across different populations. Building on this growing body of knowledge, a number of groundbreaking studies of adult literacy skills were completed, including major assessments in Canada and the United States that provided invaluable baseline data. In addition to assessing participants’ literacy skills, these various studies also gathered extensive background information on their demographic and socio-economic characteristics (e.g., age, gender, education, labour-force status, household income and nativity status).
Health literacy lays claim to a substantial body of knowledge. The more than 1,000 published articles on the subject can be divided into four general areas of investigation: • The first area focusses on the level of literacy that the health system demands of adults in terms of their capacity to use materials, access services and seek care. Some 800 studies published between 1970 and 2006 indicate that most health-related materials are written at reading levels that exceed the reading skills of an average high-school graduate.
In the mid-1990s, the International Adult Literacy Survey (IALS), a large international collaborative study involving some 25 countries was initiated. A key feature of the IALS is that participating countries adopted a common definition and framework for measuring literacy, allowing assessments of literacy-related issues over time and among population subgroups in different language groups and countries.
• The second area focusses on differences between patients with strong reading skills and limited reading skills, and their abilities to understand and interpret information related to their health or medical regimens, hospitalization and healthy behaviours. Some 100 or so published studies indicate a clear relationship between the literacy skills of patients and a variety of health outcomes.
These assessments measured respondents’ proficiencies along three literacy scales. The first scale, prose, focussed on the knowledge and skills needed to understand and use information from texts, including newspapers and books. The second scale, documents, focussed on the knowledge and skills required to locate and use information contained in such documents as job applications, maps and train schedules. The third scale, numeracy, measured
• The third, more recent, area of research focusses on efforts to improve health literacy, either by reducing health-system literacy demands, or by improving the health-literacy skills of adults.
LITERACY in Canada
the knowledge and skills required to apply basic arithmetic operations using numbers embedded in printed information.
or diagnostic tests and follow up on courses of treatment) by understanding health alerts on TV or in newspapers or understanding letters about test results.
A new international comparative study now underway, the Adult Literacy and Life Skills Survey (ALL), includes several refinements to the IALS. Most important to considerations of health literacy, the ALL also includes a series of commonly used measures of self-reported health status. International comparative results from the first round of ALL data, involving seven countries, were published in May 2005, followed by Canadian national results in June 2005.
• Health-Care Maintenance: the ability to seek and form a partnership with health-care providers, including providing history forms or following directions on medicine labels, or being able to understand and discuss the merits of alternative forms of treatment with a health professional. • System Navigation: the ability to understand and to access needed health services by completing application forms, reading maps to locate appropriate facilities or understanding health-benefits packages.
What is the current state of thinking in regard to measuring health literacy? In the period leading up to and following the release of the first round of the ALL data, methodologies for assessing health literacy have been further enhanced. They now include examining health literacy skills in a variety of health contexts and against the almost daily health-related activities that take place in homes, worksites and community systems. These new and more sophisticated scales for assessing and ranking individual and collective health-literacy scores now include:
What do the initial analyses of the health-literacy scales for Canada reveal? • As is the case with national scores on literacy and numeracy, the overall average level of health literacy in Canada is low. • 60% of adult Canadians (ages 16 and older) lack the capacity to obtain, understand and act upon health information and services and to make appropriate health decisions on their own. In addition, the proportion of adults with low levels of health literacy is significantly higher among certain groups, a finding that raises questions of equity.
• Health Promotion: the ability to enhance and maintain health (e.g., plan an exercise regime or purchase healthy foods) by locating and using health-related articles in magazines and brochures, or information contained on charts or food or product-safety labels.
• Canadian adults with less than a high-school education perform well below adults with higher levels of education and this gap widens with age. This might suggest that the aging process amplifies initial levels of education-based inequality.
• Health Protection: the ability to safeguard individual or community health (e.g., the ability to select from a range of options) by reading newspaper articles, postings about health, safety or air and quality reports or participating in referenda.
• Average health literacy varies significantly by province and territory. Yukon Territory demonstrates the highest level of official language health literacy and Nunavut the lowest.
• Disease Prevention: the ability to take preventive measures and engage in early detection (e.g., determine risks, seek screening
LITERACY in Canada
• Differences in literacy and numeracy skills exert a profound influence on a range of social, educational and economic outcomes. Differences in average health-literacy skill seem to be associated with large differences in perceived general health status.
• Other outcomes could include reductions in the average cost of treatment as a result of reductions in the duration of treatment, the substitution of lower-cost health services and reductions in misdiagnoses and medication errors. There could also be fewer preventable workplace injuries and accidents and an associated increase in labour productivity.
• Large differences in average literacy exist between different population sub-groups within Canada—especially among the elderly.
• Finally, raising the level of health literacy could also help reduce current levels of social inequality in health outcomes.
• Canadians have higher levels of health literacy than do Americans.
These benefits are far from trivial at a time when governments are struggling to find ways to contain the rapid growth of health costs.
What are some of the public policy issues flowing from this report? • The link between health literacy and health status is a cause for concern. While not perfect, the health-literacy scales developed to support this analysis provide insights that carry implications for both policy and further research.
What are the next steps? Further research is needed to provide empirical confirmation that health literacy has a causal relationship to important health outcomes and to explore why the relationship of health literacy to perceived health status varies so much from province to province.
• Low levels of health literacy stem in part from Canada’s aging population, shrinking youth cohort and growing immigrant population. Health-literacy skills will not improve unless the issue is dealt with at the policy level.
Additional analyses of the ALL health-literacy database are currently underway. Funded by the Canadian Council on Learning, these analyses should provide a much clearer portrait of the human cost of health literacy and the potential benefits that would accrue to an investment in raising the level of health literacy among Canadian adults.
• The health-care system needs to do a better job of managing seniors, who tend to have the lowest levels of health literacy. • The differences in health status associated with differences in health literacy are large enough to imply that significant improvements in overall levels of population health might be realized if a way could be found to raise adult health-literacy levels. • Taking steps to raise health-literacy skills while decreasing the challenges of navigating our health-care system might turn out to be lowcost approaches to improving overall levels of health and well-being. We could see significant reductions in the demand for health goods and services as skilled individuals assume more responsibility for managing their own health.
The genesis of health literacy Researchers and policy-makers in health and in eduÂ cation increasingly consider health literacy to be a critical pathway linking education to health outcomes, and as a contributing factor in health disparities and population health overall.
In the United States, the central role of reading and numeracy skills caught the attention of those in health fields as the findings of the 1992 U.S. National Adult Literacy Survey were disseminated.
At the same time, the Journal of the American Medical Association published a white paper by the AMA Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs3 that reflected medicineâ€™s growing recognition of literacy and its role in health care.4
By the end of the 20th century, a strong foundation for health-literacy studies was well established with more than 300 published studies in public health and medical journals.1
In 2003, HHS issued an action plan to improve the health literacy of U.S. adults. The following year, the Agency for Healthcare Research and Quality assessed publications in the field and concluded that approximately 50 studies had established a robust relationship between reading skills of patients and various health outcomes.5 Finally, the Institute of Medicine of the National Academies of Science convened a committee to examine issues and definitions associated with health literacy and published its report in 2004 with recommendations for research, practice, and policy.6
At the start of the new millennium, several seminal reports established health literacy as an area of inquiry that would shed light on pathways linking education and health outcomes. The U.S. Department of Health and Human Services (HHS) included a call to improve health literacy among the health goals and objectives for the nation as articulated in the document Healthy People 2010.2
The genesis of health literacy
Overall, the findings from large-scale adult literacy surveys offered critical insight into literacy as a possible pathway between education and health outcomes. In an effort to shed further light on the nature of the health-literacy skills of North American adults, Statistics Canada, the U.S. National Center for Education Statistics, the Educational Testing Service and the School of Public Health at Harvard University established a joint project to define health literacy and to derive a first set of provisional estimates of the distribution of health literacy in the U.S. and Canadian adult populations.
In Canada, issues related to reading skills began to catch the attention of those in the health field with the publication of Broken Words: Why Five Million Canadians are Illiterate7—an analysis of Canada’s first direct assessment of adult literacy skills that borrowed its approach from the U.S. NALS study. One of the first tangible responses involved a project spearheaded by the Ontario Public Health Association and Frontier College (1989–93). This initiative produced two reports linking literacy and health.8,9
The primary goal of this paper is to report an initial set of comparable estimates for Canada that have been derived from the 2003 Adult Literacy and Life Skills Survey (ALL). The report draws from the 2004 ETS report Literacy and Health in America, which provided the first analysis of health-literacy proficiencies among adults in the United States, and from the forthcoming comparison and contrast of the distribution of adult health literacy in Canada and the United States.
Partly as a result of this project, in 1994 the Canadian Public Health Association (CPHA) established the National Literacy and Health Program (NLHP) with funding from the federal government’s National Literacy Secretariat. Through the NLHP, CPHA has collaborated with 27 national partners in health and literacy and provided leadership in the field through a plain-language service, two national conferences and other activities at national and international levels.10 Canadian interest was enhanced by the publication of findings from successive rounds of the International Adult Literacy (IALS).11,12,13 These reports provided insight into a relationship of literacy and numeracy skills to a variety of mundane tasks—including those related to health—normally undertaken by adults in daily life.
Chapter 2 1
The Field of Health Literacy Several decades of health studies in the United States, Canada, Britain and Europe have established strong links between health status and educational attainment and/or incomeâ€”both commonly used as markers of socio-economic status (SES). However, findings from surveys of adult literacy skills have highlighted the fact that literacy influences oneâ€™s ability to access information and to navigate in the highly literate environments of modern society. Analyses of health materials published before and after the 1993 publication of the National Adult Literacy Survey (ALS) findings indicated a mismatch between the reading level of health materials and the average reading skills of adults. Studies in the latter half of the 1990s yielded statistically significant differences in health-related knowledge and behaviors between those with strong reading skills and those with limited skills. At the start of the new century, the United States National Institutes
thE fiEld of hEalth litEracy
of Health called for research proposals examining components of education for possible pathways to health. Literacy—and its implications for health outcomes—is the focus of a growing number of research studies in health.
“The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.” HEALTHY PEOPLE 2010 U.S. HEALTH AND HUMAN SERVICE
Several working definitions of health literacy are found in the published literature in the U.S., Canada, England, and Australia. The most commonly cited definition is one that emphasizes the skills of individuals: The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions. However, as greater attention is being paid to the increasingly complex nature of health activities and health care in all industrialized nations, practitioners and researchers are acknowledging that health-literacy results from the interaction of individuals’ skills with health systems’ demands. Consequently, attention is being paid to improving health literacy both by increasing adults’ literacy skills and by decreasing the literacy related demands of health systems. The Institute of Medicine report, Health Literacy: A Prescription to End Confusion,14 highlights the importance of a thorough understanding of adults’ health-literacy skills and of the literacy related barriers to health activities, care and treatment, noting that both are needed to structure a firm foundation for change and improvement. Publications in peer-reviewed journals in medicine, health education, and public health offer evidence of a growing interest in the health-related implications of limited literacy skills. The field of health literacy lays claim to a substantial body of literature. The number of studies and editorials addressing health literacy published between 2000 and the end of 2006 is more than double the number published between 1970 and 1999. Overall, the body of literature with some consideration of health literacy currently consists of approximately 1,000 articles. Furthermore, researchers from a broad spectrum of health fields—now including those from the dental and mental health fields—have published findings related to health literacy. National conferences, white papers, and reports from prestigious agencies and academies have put health literacy on the policy agenda of several industrialized nations. The research literature in health literacy can be divided into four areas of inquiry. The first focusses on the demands of health systems and the match between system demands and skills of adults who use
The Field of Health Literacy
materials, access services and seek care. Approximately 800 studies published between 1970 and 2006 indicate that most health-related materials are written at reading levels that exceed the reading skills of an average high-school graduate. The second area of inquiry focusses on differences between patients with strong reading skills and patients with limited reading skills related to knowledge of disease and medical regimen, hospitalization, a variety of health behaviors, and physical markers of health status. Approximately 100 published studies indicate a clear relationship between literacy skills (generally measured as reading skills) of patients and a wide variety of these health-related outcomes. Third, a small but growing number of studies are focussed on efforts to improve health literacy. Some of these efforts are focussed on reducing health-system demands and the elimination of literacy related barriers; others are focussed on improving the health-literacy skills of adults. Finally, new research efforts are focussed on the numeracy15 and listening and speaking skills so critical to public health communication, and to the dialogue between clients or patients and a variety of health providers. The proficiencies, assumptions, and processes of lay adults and of practitioners in the health sector are undergoing scrutiny by policy-makers, researchers, and practitioners focussed on improving health outcomes.
Chapter 3 1
MEASURING PROFICIENCIES OF ADULTS Measures of Adult Literacy Over the past decade or so, advances in psychometrics, cognitive theory and household survey methods have enabled researchers to conduct direct assessments of adult skill levels. By administering carefully designed tests to representative samples of adults, these large-scale assessments provided the worldâ€™s first valid, reliable, comparable and interpretable data on the distribution of literacy skill and its relationship to individual outcomes. The first such study was the 1992 National Adult Literacy Survey (NALS), undertaken in the U.S. by the Educational Testing Service (ETS) for the U.S. Department of Education.16 The NALS survey was the largest and most comprehensive assessment ever undertaken of the literacy proficiencies of Americaâ€™s adult population (16 years and older).
mEaSuring ProficiEnciES of adultS
technical support of Statistics Canada, Educational Testing Service, and the National Center for Education Statistics in the U.S. Department of Education.21 As with the NALS, a comprehensive background questionnaire in the IALS assessment captured information on respondents’ demographic and socio-economic characteristics, their labour market and participation in adult learning and their literacy practices. The international assessments took place in three stages, beginning in 1994 and continuing through 1998. Some 25 nations took part in the IALS project; most were in North America and Western Europe, but other countries included Australia, Chile, New Zealand and several Eastern European nations (Hungary, the Czech Republic, Slovenia, Slovakia, and Poland).
Many of the literacy concepts and measures underlying the NALS assessment were originally developed by ETS in two earlier assessments of specific sub-populations: the nation’s young adult population (21–25 years old) and of unemployed and economically disadvantaged adults served by unemployment insurance and employment and training programs funded by the U.S. Department of Labor.17 The NALS assessment provided information on the literacy proficiencies of a sample of 26,091 adults 16 and older, including a sample of 1,147 adults in federal and state prisons, as well as supplemental samples from 12 states yielding state representative samples.18 In addition to assessing participants’ literacy skills, the NALS gathered extensive background information on their demographic and socio-economic characteristics (e.g., age, gender, nativity status, educational experiences, labour-force status, household income) and on their literacy practices.
definition and fraMeWork A unique aspect of these large-scale surveys is that they adopted the same definition and framework for measuring literacy and linked all of the proficiency data to a common set of scales. This approach allows one to examine literacyrelated issues over time and among population and language subgroups in different countries. The definition of literacy was as follows:
During the same time period, two large-scale national assessments of Canadian adult literacy skills were undertaken, employing methods adapted from the U.S. studies. In 1987, the Creative Research Group fielded an assessment for the Southam newspaper chain.19 In 1989, Statistics Canada administered the Literacy Skills Used in Daily Activities (LSUDA)20 on behalf of the Secretary of State for Canada. Both studies yielded interesting findings about the level and distribution of adult literacy and its relationship to individual life chances, but little explicit information on how the measured skills might influence health status.
Using printed and written information to function in society, to achieve one’s goals and to develop one’s knowledge and potential. The assessments measured respondents’ proficiencies along three literacy scales: prose, document and quantitative. Prose literacy focussed on the knowledge and skills needed to understand and use information from texts, including editorials, news stories, poems, and fiction. Document literacy focussed on the knowledge and skills required to locate and use information contained in materials that include job applications, payroll forms, transportation schedules, maps, tables and graphs.
Following upon the NALS, Southam and LSUDA studies, a pioneering effort was undertaken to employ the same methods in a comparative assessment of adult literacy at the international level. The International Adult Literacy Survey (IALS) involved the joint efforts of participating national governments, their statistical agencies and research bureaus, the Organisation for Economic Co-operation and Development (OECD), and the
Measuring Proficiencies of Adults
Finally, quantitative literacy measured the knowledge and skills required to apply arithmetic operations, either alone or sequentially, using numbers embedded in printed materials.
comparative results from the first round of ALL data collection, which involved seven countries,23 were published in May 2005, followed by Canadian national results in June 2005.
A new international comparative study of adult skills currently underway was designed to refine and extend the IALS estimates. The Adult Literacy and Life Skills Survey (ALL) includes several changes and enhancements to previous surveys.
Contexts, Texts, and Tasks The assessments of adults’ literacy proficiencies all focus on contexts, texts, and tasks. Materials, and the activities associated with the materials, were drawn from various contexts of everyday life. Six context categories were identified to help ensure that no one group of adults is either advantaged or disadvantaged and included materials and tasks related to home and family, health and safety, community and citizenship, consumer economics, work, and leisure and recreation.
First, the quantitative measure, with its focus on basic math skills, was refined and replaced with a numeracy measure that focusses on the ability to interpret, apply, and communicate mathematical information in commonly encountered situations. Next, the ALL added an assessment of problemsolving skills, defined as the ability to apply cognitive processes toward determining a solution when that solution is not immediately apparent or obvious to the problem solver.
In addition, the literacy assessments included a range of materials and text types. Specific features of the texts were analyzed for level of complexity. In addition, tasks were characterized into groups to include the processes used to relate information in the question (the given information) to the necessary information in the text (the new information), as well as the processes needed either to identify or construct the correct response from the information available. These strategies included locating, cycling, integrating and generating information as well as formulating and calculating for the quantitative tasks. A summary discussion of the definition and framework used in the NALS and IALS, and an analysis of how these factors contribute to our understanding of what the literacy scores mean can be found in The International Adult Literacy and Life Skills Survey. Measuring Literacy and Life Skills: New Frameworks for Assessment.24 An abridged version of the framework can be found in an ETS monograph, The International Adult Literacy Survey: Understanding What Was Measured.25
Furthermore, the ALL enhanced background information. Included are measures of use of information and communication technologies, defined as the ability to integrate and apply the cognitive and technical skills that are associated with performing tasks using information and communication technologies. This measure includes cognitive as well as technical proficiency. Most important to considerations of health literacy, the ALL included commonly used measures of health status, including a self rating of health as well as the SF-12® Health Survey. This latter instrument is a 12item short form of the SF-36® physical and mental component summary scales (referred to as PCS-36 and MCS-36, respectively). The twelve SF-36® items and improved scoring algorithms reproduce at least 90% of the variance in PCS-36 and MCS-36 in both general and patient populations, and reproduce the profile of eight SF-36® health concepts sufficiently for use in large sample studies.22 International
Measuring Proficiencies of Adults
Respondents scoring in Levels 1 or 2 can best be characterized as possessing very limited to restricted literacy proficiencies. While few of the adults in Levels 1 or 2 would be considered illiterate in the historical meaning of that term—an inability to write one’s own name or to read and understand a very simple passage—few have the skills many believe are needed to succeed in today’s more technologically sophisticated economy, to gain access to high-wage jobs, or to actively participate in civic and political life. For example, adults who scored in the Level 1 to Level 2 range are performing below the average proficiencies of adults who graduated from high school. In fact, those in Level 1 are performing below the average score of adults who dropped out of high school and never earned a diploma or its equivalent.
Proficiency scores on each of the three NALS/ IALS literacy scales and the four ALL scales were estimated using an Item Response Theory (IRT) statistical model. These models, a variant of latent trait models, are powerful because they allow one to empirically confirm the relative difficulty of items predicted by theory, and by extension proficiency.26 Scores on each scale ranged from 0 to 500 and were characterized using five levels that capture the progression of complexity and difficulty. Level 1 represents the lowest level of proficiency and Level 5 the highest. Table 1 below provides the score range for each level of proficiency. A number of national and state organizations in the U.S., including the National Governor’s Association, have identified Level 3 proficiency as a minimum standard for success in America’s labour markets.27 Analyses produced by the OECD and Statistics Canada at the international level reach the same conclusion, citing evidence that associates the boundary between levels 2 and 3 with a rapid improvement in labour-market and other individual outcomes. In addition, HRSDC’s Essential Skills Profiles identify Level 3 as the minimum requirement for the majority of Canadian occupations (HRSDC, 2007).
Levels in the IALS and NALS are assigned probabilistically with individuals placed at a level if they get 80% or more of items correct at that level. It is highly likely that individuals perform better with familiar tasks that they encounter on a regular basis in their daily lives than their placement on these scales would suggest. Unfortunately, change in skill demand is an inevitable consequence of technological and social change and an inescapable result of changing roles over the life course. The NALS, IALS and ALL measures are meant to reflect the degree to which individuals possess the skills to handle unfamiliar tasks of identical difficulty that they encounter as change influences their lives.
Table 1: Range of Scale Scores Corresponding to Each Literacy Level Level
Chapter 4 1
MEASURES OF HEALTH LITERACY In a thoughtful analysis of the emerging field of health literacy, the Institute of Medicine Committee on health literacy noted that instruments used by health researchers had not offered a sufficient assessment of health literacy. The instruments were essentially approximations of reading skills alone and did not capture the full complement of literacy skills as applied in health contexts. In addition, at the time the report Health Literacy: A Prescription to End Confusion was published, there was no populationbased data on health-literacy skills. Both the IOM report and the ETS report Literacy and Health in America were issued in spring 2004. The ETS report, discussed in detail below, was the first analysis of population-based health-literacy skills among adults. At the same time, however, plans were underway to offer an analysis of adultsâ€™ health-literacy skills in the second U.S.-based national adult literacy survey. The U.S. Department of Health and Human 16
Measures of Health Literacy
Services (HHS) worked with the Department of Education to insert a number of specific healthrelated items in the follow-up to the 1993 NALS. The National Assessment of Adult Literacy (NAAL), fielded in 2003, included a purposive sample of materials and items (n=28) related to health and representing three domains of health and healthcare information and services: clinical, prevention and navigation of the health-care system. Each of the 28 items followed the same format and structure of other materials and tasks on the literacy assessment instrument.
Each day millions of adults must make decisions, take actions, and consider issues that influence not only their own well-being, but also that of their family members and of their community. However, health researchers have not systematically examined tasks in these settings nor have they critically examined the materials adults are expected to use in order to accomplish tasks. Adults’ ability to use a wide variety of health-related materials—including package labels found on foods, household goods, cleaning products and over-the-counter medicines— could influence health outcomes.
These items were analyzed independently to serve as a measure of progress for the healthliteracy objective in Healthy People 2010 and subsequent years. The schema and items used for the ETS study were not included in the analysis. In addition, several changes were made in the analytic processes for the 2003 NAAL data. These changes were related to the sampling parameter, to the performance levels used to identify and characterize the participants, and in the level set for the probability of doing a task correctly.28 As a result, it would be cumbersome to compare the NAAL health-literacy measure and findings with the health-literacy measure, analytic processes and findings discussed here. At the same time, the report, The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy, should be of interest to readers of this analysis and is cited below.29
A Framework for Understanding Health Literacy The first step undertaken to analyze adults’ healthliteracy skills was to consider a variety of health activities and behaviours related to where and why people take health-related actions. For the initial analysis, Rudd adopted a commonly used lexicon to differentiate among various health-related activities. The health-related activities undertaken by adults in daily life are divided into the following categories: health promotion, health protection, disease prevention, health care and navigation.
Health Promotion Generally, the emphasis in health promotion is placed on activities undertaken by individuals for their own health and encompasses behaviours related to nutrition, physical activity and other healthy habits.
The analytic reports focussed on the field of health literacy—including the IOM report referenced above—called for an expanded scope of inquiry. It encouraged researchers to move beyond the medical encounter to examine health-literacy issues in a variety of health contexts and for the multiple health-related activities that take place in homes, worksites and community-based settings, as well as in health and health-care systems.
Actions taken in everyday life to preserve and protect health are highlighted in traditional epidemiologic models. These activities include learning about changes in products, improving the design of structures, machines, products, systems or process, and understanding the rules governing details or procedures. In addition, these activities are undertaken to protect the health of groups
Measures of Health Literacy
als and nurses. Patient education brochures, labels for medical and dental products, and directions for care are some of the materials patients and family members must use to understand a disease or illness, follow recommended guidelines, prepare for tests and procedures, engage in self-care and manage a chronic disease.
of people (such as workers or people living in a specific geographic location) and the public at large (all those who purchase food or drink water). The Institute of Medicine issued two reports on the scope of public health and in each highlighted the importance of public engagement in community action to ensure the health of the public.30,31 Included in the report are activities related to occupational health and safety and to safeguarding the environment. These activities are linked to mandates from governmental agencies such as the U.S. Federal Drug Administration, Health Canada and Environment Canada, or are specified in federal legislation such as the Right to Know Act in the U.S. and in federal and provincial occupational health and safety legislation in Canada. Materials coded under protection include discourse related to product safety and to health-related social and environmental issues.
Navigation Finally, attention to barriers to programs, services and care has shaped a fifth health-literacy activity: one related to bureaucratic demands and referred to as navigation. Navigation of the health-care system encompasses activities related to rights and responsibilities, application for insurance and other coverage plans, and informed consent for procedures and studies. The schema enabled Rudd, Kirsch and Yamamoto to examine and code all of the materials and tasks used across various assessments of adult literacy skills and to link them to the precursor NALS database. In American research, these results are referred to as the Health Activities Literacy Scale (HALS).32
Disease Prevention Disease prevention activities include actions undertaken to prevent the onset of an illness or a disease or to detect diseases at early stages. Included here are activities related to immunization, such as those for infants and school children, or influenza and pneumonia inoculations for elders. Screening programs range from routine vision and hearing examinations to prostate or breast cancer tests. In addition, actions such as the use of sunscreen are included.
The items that were used to create the health activities literacy scale were drawn from the hundreds of literacy tasks that had been developed for various large-scale assessments of adult literacy, all of which used the same definition of literacy and framework for constructing literacy tasks. Table 2 offers a description of the five health activities, with examples of materials adults are expected to use and examples of tasks they are expected to undertake.
Health Care Health-care activities focus on learning about an illness or disease, taking action to seek care, complying with the appropriate regimen, monitoring and measuring medicine and symptoms for chronic disease management, and engaging in dialogue and discussion with care providers such as dentists, doctors, pharmacists, mental health profession-
The following section provides a brief overview of the coding process and the creation of the new scale for a measure of health-literacy skills (HLS).
Measures of Health Literacy
Coding the Literacy Items
Table 2: Categories of Health Activities with Selected Examples Health Activities
Examples of Materials
Examples of Tasks
Enhance and Articles in maintain health newspapers and magazines, booklets, brochures Charts, graphs, lists Food and product labels
Purchase food Plan exercise regimen
Safeguard health of individuals and communities
Articles in newspapers and magazines Postings for health and safety warnings Air and water quality reports Referenda
Decide among product options Use/avoid products
News alerts: TV, radio, newspapers Postings for inoculations and screening Letters related to test results Graphs, charts
Determine risk Engage in screening or diagnostic tests Follow up
Health history forms Medicine labels Discharge instructions Education booklets and brochures, health information on the Internet
Describe and measure symptoms Follow directions on medicine labels Calculate timing for medicine Collect information on merits of various treatment regimes for discussion with health professionals
Take preventive measures and engage in early detection
Health Care and Seek care Maintenance and form a partnership with healthcare providers
Access needed services Understand rights
Maps Application forms Statements of rights and responsibilities, informed consent Health-benefit packages
Locate facilities Apply for benefits Offer informed consent
Three researchers independently coded the materials and questions from previous literacy assessments into one of the five health-related activities identified above; all differences were resolved through discussions and refinement of the coding criteria. Of the 350 unique assessment items, some 191 literacy tasks, drawn from the surveys used in the United States, were judged to measure health-related activities. Of those 350 assessment items, some 235 literacy tasks administered for Canada were derived from the Canadian component of the 2003 ALL survey.33 The 2003 ALL survey offers a representative sample of adult Canadians aged 16 and above living in the ten provinces and three territories. The sample excluded adults living on reserve and non-civilian populations, including members of the Armed Forces and inmates of institutions. The Canadian data set included sufficient common assessment items to provide a strong psychometric linkage to the NALS/IALS/ ALL and HALS scales. The procedures used to create and validate the healthliteracy scale are described in Annex A. Analyses of the resultant proficiency scales have been published for the U.S. (ETS, 2006). For Canada, an initial analyses of the health-literacy scales are presented in the next chapter.
CHAPTER 5 1
THE DISTRIBUTION OF HEALTH LITERACY IN CANADA Analyses of the health-literacy scales for Canada reveal several important findings as outlined below. Large differences exist in the average level of adult health literacy between countries. Canadian men outperform their American counterparts by roughly 12 points. Canadian women outperform their American peers by roughly 15 points. These differences are larger than the differences in the underlying cognitive skills such as literacy and numeracy, which raises questions about the underlying causes of the differences and their impact on population health.
Figure 1: A comparison of average health-literacy scores for Canadian and American men and women, aged 16â€“65 270 265
Canada Male Canada Female
United States Male United States Female
250 245 245 250 255 260 265 270
source: Adult Literacy and Life Skills Survey, 2003
thE diStriBution of hEalth litEracy in canada
Large differences in average literacy also exist between different population sub-groups within Canada.
Figure 3 confirms that average health literacy varies significantly by age and education. As expected, adults with less than a high-school education perform well below adults with higher levels of education. Interestingly, the gap in performance for this group widens with age, a finding that might suggest the aging process amplifies initial levels of education-based inequality. The 70-point gap in average health-literacy scores for the most and the least educated seniors aged 66 and over is roughly equivalent to the health literacy gain associated with three additional years of education.
Figure 2 reveals that average health literacy varies significantly by province. The Yukon Territory demonstrates the highest level of official language health literacy and Nunavut the lowest. The gap in average scores between Nunavut and the Yukon is significant—roughly equal to the increase in health literacy associated with two years of additional education. The rank order of jurisdictions by average health-literacy score differs considerably from rankings based on prose literacy, document literacy and numeracy, with several provinces performing well below the national average.
Figure 3: Average health-literacy score, by age group and education level, Canada, 2003
Figure 2: Average health-literacy scores, population aged 16 and over (including seniors), Canada, provinces and territories 95% Confidence interval
Saskatchewan Alberta British Columbia Northwest Territories
16–25 26–35 36–45 46–55 56–65 66+ Age group
Less than high school Post-secondary, non-university
Estimated average score
290 270 250 230 210 190 170
High school University
source: Adult Literacy and Life Skills Survey, 2003
Large differences also exist in the proportions of adults at various health-literacy proficiency levels, both within and between countries.
New Brunswick Manitoba
Ontario Prince Edward Island Newfoundland and Labrador Nunavut Health-literacy score source: Adult Literacy and Life Skills Survey, 2003
thE diStriBution of hEalth litEracy in canada
Figure 4: This chart compares and contrasts the distribution of health literacy by level in Canada and the U.S., population aged 16â€“65
source: Adult Literacy and Life Skills Survey, 2003
The chart shows that relatively fewer Canadian adults fall in the three lowest proficiency levels, and relatively more Canadian adults in the three highest proficiency levels than their American peers.
Estimated average score
Fair Poor 200
It would appear that the observed differences in health literacy are largely predictable. Analyses of the determinants of health literacy in Canada (including educational attainment, mother tongue, immigrant status and the intensity of the skill used) explain roughly 60% of the observed variance in health-literacy skill, a fact that opens the way to policy intervention. Interestingly, the relative impact of the underlying determinants differs markedly from those that influence the development of the constituent cognitive skills (prose literacy, document literacy and numeracy).34
95% Confidence interval
Excellent and Very Good
Levels 4 and 5
Levels 0 and 1
Figure 5: Average health-literacy scores by self-perceived general health status, population aged 16 and over (including seniors), Canada
45 40 35 30 25 20 15 10 5 0
associated with two and a half years of additional schooling. It is this link between health literacy and health status that is of interest to policy-makers. Provided that health literacy generates health, policies aimed at increasing levels of health literacy might turn out to be low-cost alternatives to existing practice.
Health-literacy score source: Adult Literacy and Life Skills Survey, 2003
Figure 6: distribution of low health-literacy levels The Canadian map in this chart illustrates the geographical distribution of lower healthliteracy skills, based on local area estimates. The map shows the percentage of the adult population (ages 16 and older) with health-literacy skills that are considered to be at level 2 and below, according to the 2003 International Adult Literacy and Life Skills Survey (IALSS) and information from 2001 Census. Clearly, health literacy varies considerably throughout the country and within each region. Such information will help health and literacy organizations, health professionals and governments to develop specific practices, programs and policies to improve health literacyâ€”and consequently health outcomesâ€”across Canada.
The differences in average health-literacy skills and the proportions at low levels revealed above would be only of passing interest were it not for the fact that they seem to be associated with large differences in perceived general health status. Figure 5 reveals an almost 60-point difference in average health-literacy scores between adults reporting excellent and poor general health status, roughly equal to the increase in health-literacy skill
The Distribution of Health Literacy in Canada
Figure 6: Proportion of adult health literacy at level 2 and below, ages 16 and older
Source: These results are derived from estimates for a geographical area based on the 2003 International Adult Literacy and Skills Survey (IALSS). The estimates are achieved by combining an areaâ€™s results with those from neighbouring areas. They also factor in several characteristics of the area, from the 2001 Census, such as education and income. The geographical unit used in the map is Statistics Canadaâ€™s dissemination area (DA), which is the smallest standard geographic area for which all census data are disseminated. DAs have a population of between 400 and 700 people. The analysis and mapping of the health-literacy results were conducted by J. Douglas Willms, Canada Research Chair in Human Development at the University of New Brunswick (UNB), with the assistance of Teresa Tang, GIS Programmer at the Canadian Research Institute for Social Policy at UNB.
Chapter 6 1
SUMMARY AND CONCLUSIONS Analysis of the NALS, IALS and ALL studies has provided incontrovertible evidence of four things: • Literacy and numeracy skills reflect more than measurements of educational attainment; they capture differences between the quality of initial education and skills gained or lost in adulthood. • Differences in literacy and numeracy skills exert a profound influence on a range of individual social, educational and economic outcomes. • Differences in the level and distribution of literacy and numeracy skill lead to large differences in the economic wealth of nations. • The social and economic processes that underlie skill acquisition, maintenance and loss are complex.
Summary and Conclusions
Implications for Policy
These findings have attracted the attention of a range of social, educational and economic researchers, policy-makers and practitioners around the world and have precipitated major policy responses in several countries, including the U.K., Sweden, Ireland and the Netherlands.
The differences in health status associated with differences in health literacy are large enough to imply that significant improvements in overall levels of population health might be realized if a way could be found to raise adult health-literacy levels.
To date, however, health researchers, policy-makers and practitioners have largely ignored these results. This is surprising given that those in the health fields have long known of strong associations between education (as measured by grade completed) and health (as measured by health status, morbidity and mortality). Health researchers had not, however, closely examined components of education to explore explanations for this association or the pathways linking education and health.
The same logic suggests that other benefits might flow from increases in health literacy. First, significant reductions in the demand for health goods and services might be realized as skilled individuals assumed more responsibility for managing their own health. Second, reductions in the average cost of treatment might result from reductions in the duration of treatment, the substitution of lower-cost health goods and services provided by relatively expensive health professionals, and reductions in misdiagnosis and improperly prescribed medication.
Literacy and numeracy skills have historically been considered the foundation skills of education. The findings presented in this report confirm that many adults lack the health-literacy skills needed to confront independently their needs for health information.
Third, a reduction in the prevalence of preventable workplace injuries and accidents, and an associated increase in labour productivity are possible results.
As is the case with literacy and numeracy skills, the overall average level of health-literacy skill is low. In addition, the proportion of adults with low levels of health literacy is significantly higher in some groups of adults, a finding that raises questions of equity.
Finally, the evidence suggests that current levels of social inequality in health outcomes could be reduced. These benefits are far from trivial at a time when governments are struggling to find ways to contain the rapid growth of health costs.
The fact that health literacy appears to be linked to health status is a cause for concern. While not perfect, the health-literacy scales developed to support this analysis reveal interesting insights that carry implications for both policy and further research.
Summary and Conclusions
Implications for further research
Second, it would be useful to find ways to confirm empirically the fundamental assumption that underlies the available analyses of health literacy: that health literacy has a causal relationship to a range of important health outcomes, including the prevalence of disease, the cost of treatment and lost productivity. This could be accomplished at low cost by linking the ALL survey responses to administrative records drawn from the health system. Several provinces, including Manitoba, Quebec and British Columbia have the data and technical infrastructure to undertake such linkages.
The results presented on page 25 are sufficiently interesting to justify further investment and suggest several priorities for future research. In the near term, more detailed analyses of the health-literacy scales should be undertaken. Such analyses are underway, with CCL planning to release a full-length monograph in 2008.35 This monograph will profile the social distribution of health literacy and explore the factors that underlie observed differences in skill levels and health literacyâ€™s relationship to individual health.
Third, it would be useful to explore the costs and modalities of raising the health-literacy levels of adults so that the efficacy of such investments could be compared to other policy options.
Over the longer term, several pieces of research might help to reveal the causes and consequences of health literacy.
Finally, it would be useful to explore why the relationship of health literacy to perceived health status varies so much from province to province. Such variation implies that some provinces have been far more successful than others at attenuating the negative consequences of low health-literacy levels. It would be interesting to see how they achieved this and at what cost.
First, it would be useful to develop and administer a comparative adult health-literacy assessment, one that assures each of the Rudd health-literacy subdomains is sampled systematically and at a rate that represents its relative importance in meeting prevailing health-literacy demands. Development of a focussed health-literacy assessment would also include some conceptual development that incorporates the empirical insights afforded by analyses of the ALL health-literacy scales.
Chapter annex A 1
Methodological Approach to Creating the HALS The various surveys from which the 191 healthrelated literacy tasks were selected represent different populations with various demographic characteristics. Current methodologies provide researchers with the tools they need to evaluate the performance of people even when they have been given somewhat different tasks and when they represent different samples and populations studied over time.36 These methodologies have been used with student surveys such as the National Assessment of Educational Progress (NAEP) and the Programme for International Student Assessment (PISA), as well as the adult surveys discussed in this report. Therefore, even though the populations studied varied somewhat across the different surveys, the subsets of literacy tasks and the scoring rubrics common across the surveys were kept constant and their item parameters checked for stability across each survey. Over the years, the same item parameters have been 27
Methodological Approach to Creating the HALS
found to fit very well to each of the subpopulations within a country, as well as across countries with different languages.
three statistical indices that estimate the fit of each item for each population against the common item parameter (X2 statistic, the Root Mean Squared Deviation statistic and the Weighted Mean Deviation); and the impact of the item parameter on the overall proficiency estimate of a particular population. Deviations are based on the difference between model-based expected proportions correct and observed proportions correct at 41 equally spaced ability scale values. The fit of the health-related literacy tasks was remarkably good based on any conventional standard. Therefore, a single set of common item parameters could be used to describe all survey samples.
Once the health-related literacy tasks had been scaled, the stability of the new item parameters was verified across each of the surveys to ensure they fit well. More than 58,000 respondents from across the various adult surveys were used to estimate and verify the health-related literacy item parameters. Because the focus of the current study is the Canadian population, the creation of the health activities literacy scale used only samples from the U.S. The scaling model used for the health literacy of the IALS data is the two-parameter logistic (2PL) model from item response theory.37 Item response theory (IRT) is a mathematical model for the probability that a particular person will respond correctly to a particular item from a domain of items. This probability is given as a function of a parameter characterizing the proficiency of that person, and two parametersâ€”difficulty and discriminationâ€”that characterize the properties of that item. One of the strengths of IRT models is that when their assumptions hold and estimates of the modelâ€™s item parameters are available for the collections of items that make up the different test forms, all results can be reported directly in terms of the IRT proficiency. This property of IRT scaling removes the need to establish the comparability of number-correct score scales for different forms of the test.
The Health Activities Literacy Scale (HALS) is a new scale. Even though it is based on pre-existing items from various literacy surveys, the properties of this new scale have not been defined. That is, the scale could range from 0 to 100, from 200 to 800 or within some other pre-selected range. The procedure to align the health-literacy activities scale with the NALS scales was based on matching two moments of the proficiency distributions: the mean and standard deviation. In this study, the provisional proficiency distribution based on the health scale was matched to the distribution of means of three NALS scale proficiency values (m=271.562 and sd=65.380). This allowed us to do a linear transformation that defines HALS on a scale ranging from 0 to 500, having the same mean and standard deviation as the three NALS proficiency scales.
The stability of the item para-meters must be checked across the various survey populations to ensure the comparability of the data and the stability of the newly established scale. The common item parameters must fit well in order to justify the use of the new item parameters and to establish the stability of the new health-activities literacy scale (HALS). Five approaches were used to evaluate the stability of the item parameters, including: a graphical method that allows one to observe the item characteristic curves for various populations;
One of the benefits of HALS is that it uses items from existing large-scale surveys of adults. Several researchers reviewed each literacy task to determine how well it fit into the health-activities framework described in this report. This adds content relevance to the scale because each item was judged to be representative of a type of health activity, thus focussing the measurement on tasks that broadly define health literacy rather than general literacy. Each of the 191 items that make up HALS has been administered to nationally
Methodological Approach to Creating the HALS
representative samples of adults. Because a large number of adults responded to each item, we were able to check how well each item behaves psychometrically. For example, each item was checked for differential performance by subsets of samples. In addition, each item was checked to determine how well it fits into the overall scale.
each item and its position along the health scale. The IALS database links the HALS to an extensive set of background information. This link also contributes to the validation of the HALS. Using this information, we are able to see the correlations between HALS and a wide range of background characteristics that include: age, gender, race/ ethnicity, level of education, country of birth, health status and wealth.
Other pieces of information relating to the validity of the HALS stem from our understanding of the construct and what contributes to the difficulty of
ENDnotes 1 Rudd, R.E., B.A. Moeykens, T. Colton. “Health and Literacy: a review of the medical and public health literature, chapter in Comings J.P., C. Smith, B. Garner (eds),” Annual Review of Adult Learning and Literacy. (San Francisco, Josey-Bass: 1999). 2 Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services. Healthy People 2010, (Washington, D.C.) Available at: www.healthypeople.gov. 3 Ad Hoc Committee on Health Literacy for the Council of Scientific Affairs. American Medical Association Health Literacy: Report of the Council of Scientific Affairs, JAMA 281(6): 552-557, (1999). 4 Rudd, R.E., B.A. Moeykens, T. Colton. “Health and Literacy: a review of the medical and public health literature, chapter in Comings, J.P., C. Smith, B. Garner B (eds),” Annual Review of Adult Learning and Literacy. (San Francisco, Josey-Bass: 2000). 5 Berkman, N.D., D.A. Dewalt, M.P. Pignone et al. “Literacy and Health Outcomes,” Agency for Healthcare Research and Quality. Evidence report/technology assessment (Summary), 87: 1-8, (2004).
6 Institute of Medicine Committee on Health Literacy. Health Literacy: a Prescription to End Confusion, (Washington D.C., National Academies Press: 2004). 7 Calamai, Peter and The Creative Research Group. Broken Words. Why Five Million Canadians are Illiterate, (Toronto, The Creative Research Group: 1989). 8 Perrin, B. et al. The Research Report of the Literacy and Health Project Phase One: Making the World Healthier and Safer for People Who Can’t Read. (Toronto, Ontario Public Health Association and Frontier College: 1989). 9 Breen, M. Partners in Practice: Literacy and Health Project Phase Two, (Toronto, Ontario Public Health Association and Frontier College: 1993). 10 Canadian Public Health Association. National Literacy and Health Program, The Canadian Public Health Association, (2007). Available at: www.nlhp.cpha.ca. 11 Statistics Canada and OECD. Literacy, Economy and Society: First Results of the International Adult Literacy Survey, Statistics Canada and OECD, (Paris and Ottawa: 1995).
12 OECD and HRDC. Literacy Skills for the Knowledge Society: Further Results of the International Adult Literacy Survey, (Paris and Ottawa: 1997). 13 OECD and Statistics Canada. Literacy in the Information Age: Final Report of the International Adult Literacy Survey, (Paris and Ottawa: 2000). 14 Institute of Medicine Committee on Health Literacy. Health literacy: a Prescription to end confusion. (National Academies Press, Washington D.C.: 2004). 15 Numeracy is defined as “the knowledge and skills required to effectively manage the mathematical demands of diverse situations”. Available at: www.ets.org/Media/ Tests/ETS_Literacy/ALLS_ NUMERACY.pdf. 16 For an introduction into the purposes, design features and findings of the National Adult Literacy Survey (NALS) that was conducted in 1992 by the Educational Testing Service for the U.S. Department of Education, see: Kirsch, Irwin, S., Ann Jungeblut, Lynn Jenkins and Andrew Kolstad. Adult Literacy in America, (Washington, D.C., National Centre for Education Statistics: 1993).
17 (i) Kirsch, Irwin S. and Ann Jungeblut. Literacy Profiles of America’s Young Adults, (Princeton, New Jersey, Educational Testing Service: 1986); (ii) Venezky, Richard L., Carl F. Kaestle, and Andrew M. Sum. The Subtle Danger; (iii) Kirsch, Irwin S., Ann Jungeblut and Anne Campbell, Beyond the School Doors: The Literacy Needs of Job Seekers Served by the U.S. Department of Labor. (Princeton, New Jersey, Educational Testing Service: 1997). 18 For further information on the sample size and design of the NALS survey, see: Kirsch, Irwin S. et al., Adult Literacy in America, pp. 5–7. 19 Creative Research Group. Broken Words, (1987). 20 See Statistics Canada. Literacy Skills Used in Daily Activities (1990). 21 For a review of the purposes, design features, sample design, timing and findings of the International Adult Literacy Surveys, see: (i) Organisation for Economic Co-operation and Development and Statistics Canada. Literacy, Economy and Society: First results of the International Adult Literacy Survey, (Paris and Ottawa: 1995). (ii) Organisation for Economic Co-operation and Development and Statistics Canada. Literacy in the Information Age, Final Report of the Adult Literacy Survey, (Paris and Ottawa: 2000).
22 Ware J.E., M. Kosinski, and S.D. Keller. “A 12-item Short-form Health Survey: Construction of scales and preliminary tests of reliability and validity,” Medical Care, 34(3):220-233, (1996). 23 ALL estimates are available for Canada (in English and French), Norway, Bermuda, Switzerland (in French, Swiss German and Italian, Italy and the Mexican State of Nuevo Leon). 24 Statistics Canada. The International Adult Literacy and Life Skills Survey. Measuring Literacy and Life Skills: New Frameworks for Assessment, (Ottawa: 2005). 25 Kirsch, Irwin S. The International Adult Literacy Survey: Understanding What Was Measured, (Princeton, NJ., Educational Testing Service: 2001). Available at: www.ets.org/research/dload/ RR-01-25.pdf. 26 Murray, T.S., Kirsch, I. S. and L.B Jenkins (editors). Adult Literacy in OECD Countries. Technical Report on the First International Adult Literacy Survey, (National Centre for Education Statistics, U.S. Department of Education, Washington, D.C.: 1998). 27 Comings, John, Andrew Sum, Johan Uvin, et al. New Skills for A New Economy: Adult Education’s Role in Sustaining Economic Growth and Expanding Opportunity, (Boston, Massachusetts Institute for a New Commonwealth: 2001).
28 National Research Council. “Measuring literacy: Performance levels for adults,” Committee on Performance Levels for Adult Literacy, Houser R.M., C.F. Edley Jr., J.F. Koenig et al. (Eds). Board on Testing and Assessment Center for Education. Division of Behavioral and Social Sciences and Education. (Washington, D.C., The National Academies Press: 2005). 29 Kutner, M., E. Greenberg, Y. Jin, et al. 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, D.C., National Center for Education Statistics: 2006). 30 Institute of Medicine Committee for the Study of the Future of Public Health. The Future of Public Health, (Washington D.C., National Academy Press: 1998). 31 Institute of Medicine Committee on Assuring the Health of the Public in the 21st Century. The Future of the Public’s Health in the 21st Century, (Washington D.C., The National Academies Press: 2003). 32 Canadian readers should not confuse the Health Activities Literacy Scale with Statistics Canada’s Health Activity and Limitations Survey, which is also known by the HALS acronym.
33 Health literacy scales were also derived for Canada using the 1994 IALS data, but the estimates are only roughly comparable to the 2003 estimates due to the smaller number of health-related items and overall smaller sample size. 34 Murray, Scott, Janet Hagey, Richard Desjardins and Douglas Williams. “Healthy Reading: How Health Literacy Influences Canadians’ Health and Well-being.” (Ottawa, The Canadian Council on Learning: In press).
35 Murray, Scott, Janet Hagey, Richard Desjardins and Douglas Williams. “Healthy Reading: How Health Literacy Influences Canadians’ Health and Well-being.” (Ottawa, The Canadian Council on Learning: In press). 36 (i)Yamamoto, K. & J. Mazzeo. “Item response Theory Scale Linking in NAEP,” Journal of Educational Statistics 17.2, 155-175; (1992). (ii) Yamamoto, K. “Scaling and Scale Linking,” Technical Report on the First International Adult Literacy Survey, (National Centre for Education Statistics, 1994).
37 Lord, F. Applications of Item Response Theory to Practical Testing Problems. Lawrence Erlbaum Associates, (Hillside, N.J.: 1980).
LITERACY in Canada INITIAL RESULTS from the International Adult Literacy and Skills Survey
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