HEALTH INFORMATION SEEKING BEHAVIORS OF ADULTS WITH

LOW LITERACY, NUMERACY, AND PROBLEM SOLVING SKILLS

Exploring Results from the 2012 U.S. PIAAC Study and

Implications for Research, Policy and Practice
Jackie Taylor
Commission on Adult Basic Education
YOUR ROLE IN HEALTH LITERACY

 Indicate your role in health literacy:

 patient engagement specialist
 health care provider
 health educator
 adult educator
 communications specialist
 health care researcher
 Adult education researcher
 case manager
 student
WHAT DO WE MEAN BY HEALTH LITERACY?

Health Literacy:
“The degree to which people have the capacity to
obtain, process, and understand basic health
information and services needed to make
appropriate health decisions.”
Institute of Medicine
 PROFICIENCY IN HEALTH LITERACY
 1. What percentage of U.S. adults has
proficient health literacy?
 50

 65

 12

 87
What is PIAAC?
About PIAAC is an international large-scale assessment
PIAAC administered in 2011-12 in 23 countries

It assessed 16 - to 65-year-olds, non-institutionalized, residing in

each country, irrespective of nationality, citizenship, or language
status
Laptop computer In the U.S., 80% took the computer tests and
or paper-and- 15% took the paper-and-pencil tests.
pencil:
Assessment Literacy
subjects:
Numeracy
Problem Solving in Technology-Rich
Environments (digital problem solving)
Assessment The background survey was conducted in English or
was conducted Spanish. About 4% could not complete the BQ because
only in English of language difficulties or learning or mental
in the U.S.: disabilities, and 1% could not complete it for other
reasons.

PPT slide provided courtesy of AIR

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DEFINITIONS OF PIAAC DIRECT ASSESSMENT SUBJECTS
Literacy is understanding, evaluating, using and engaging with
written texts
to participate in society,
to achieve one’s goals, and
to develop one’s knowledge and potential.
Numeracy is the ability to access, use, interpret, and communicate
mathematical information and ideas, in order to engage in and
manage the mathematical demands of a range of situations in adult
life.
Problem solving in technology-rich environments involves using
digital technology, communication tools and networks to acquire
and evaluate information, communicate with others and perform
practical tasks.

PPT slide provided courtesy of AIR

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PARTICIPATING COUNTRIES
2012 2015
Australia Italy Chile
Austria Japan Greece
Belgium Korea, Rep of Indonesia
Canada Netherlands Israel
Cyprus Norway Lithuania
Czech Republic Poland New Zealand
Denmark Slovak Republic Singapore
Estonia Spain Slovenia
Finland Sweden Turkey
France United Kingdom
Germany United States
Ireland

PPT slide provided courtesy of AIR

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HOW PIAAC COLLECTS DATA

Direct
assessment
Background Module on of key
questionnaire skill use information-
processing
skills

PPT slide provided courtesy of AIR

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 THE MODULE ON SKILL USE COLLECTS DATA ON USE
OF THE FOLLOWING SKILLS:
Cognitive skills
reading, writing, mathematics, and use of
information and communication technologies

Interaction and social skills

collaboration and co-operation,
work and time planning,
communication and negotiation,
and customer contact

Learning skills
coaching, formal/informal
Physical skills learning and updating
use of gross and professional skills
fine motor skills

PPT slide provided courtesy of AIR

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PIAAC RESULTS ARE REPORTED IN TWO WAYS:
 Average Scores: reported on a scale of 0-500 for
all domains.

 Proficiency Levels: reported as the percentages of

adults scoring at six performance levels ( from
below level 1 to level 5) in literacy and numeracy
and at four performance levels in problem solving
in technology-rich environments (from below level
1 to level 3).

PPT slide provided courtesy of AIR

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WHAT DOES PIAAC SAY ABOUT
HEALTH LITERACY?
HEALTH MEASURES IN THE U.S. QUESTIONNAIRE

Questions included:
 Health status

 Health insurance coverage

 Sources of information about health issues

 Preventive health practices

LITERACY AND HEALTH STATUS
 Adults with lower levels of skills in literacy are more likely to report
having a fair to poor health than those with higher proficiency, even
when account is taken of education attainment and other
background characteristics.

 On average across countries, adults who score at or below Level 1 on

the literacy scale have over two times the odds of reporting fair to
poor health than those who score at Level 4 or 5.

 Adults scoring at Level 2 are also markedly more likely, on average, to

report fair to poor health even when other factors are taken into
account.

 Across countries, the chances of adults who score at Level 3

reporting poor health are not significantly different from those of
their peers at Level 4 or 5.
HEALTH STATUS
More people reported having “excellent” or “very good”
health and fewer people reported having “good” or “fair”
health when compared to the international average.
35 33 33
31
30 28

25 24

20
17 International Average
15
15 United States
11
10

5 4 4

0
Poor Fair Good Very Good Excellent
 HEALTH AND LITERACY
In literacy, U.S. adults with fair or poor health were
below the international average for those with similar
health statuses.

282
Excellent/Very Good
281

International
270
Good Average
262
United States

254
Fair/Poor
242

220 240 260 280 300

HEALTH AND NUMERACY
In numeracy, adults with fair or poor health scored
below the international average for those with similar
health statuses.
278
Excellent/Very Good
265

266
Good International Average
246
United States

247
Fair/Poor
220

0 100 200 300

GAPS IN LITERACY
 U.S. gaps in literacy scores similar to
international average by gender, smaller by
age, and larger by health.
GAPS IN NUMERACY
 U.S. gap similar to international average by
gender, smaller by age, and larger by health
status.
HEALTH STATUS BY INCOME AND EDUCATION

Adults with Higher Income

Reported Better Health

Adults with Higher Education

Reported Better Health
HOW DO WE COMPARE TO OTHER COUNTRIES?
Literacy Numeracy PS-TRE
Japan
Finland
Japan
Finland
Japan • The U.S. ranked
Finland
Netherlands
Australia
Flanders-Belgium
Netherlands
Australia
Sweden
lower than most
Sweden
Norway
Sweden
Norway
Norway
Netherlands
other countries in all
Estonia
Flanders-Belgium
Denmark
Slovak Rep.
Austria
Denmark
three domains.
Czech Rep. Czech Rep. Czech Rep.
Slovak Rep. Austria Korea, Rep. of
Canada
Korea, Rep. of
Estonia
Germany
Germany
Canada • The US ranked better
U.K. Australia Slovak Rep.
Denmark
Germany
Canada Flanders-Belgium in Literacy than in
Cyprus U.K.
United States
Austria
Korea, Rep. of
U.K.
Estonia
United States
Numeracy or
Cyprus
Poland
Poland
Ireland
Ireland
Poland
Problem Solving in
Ireland
France
France
United States
Italy
Spain technology-rich
Spain Italy Cyprus
Italy Spain France environments.
PPT slide provided courtesy of AIR 21
SUMMARY
 Lower overall scores than international average in all
three subjects
 Ranked better in literacy than in numeracy or problem
solving in technology-rich environments
 Higher percentages of low performers than
internationally
 Health status of U.S. adults better than international
average
 Larger gap in U.S. than international average in literacy
achievement by health status
 Higher income and higher educated U.S. adults report
better health
WHAT ARE HEALTH—SEEKING
BEHAVIORS OF ADULTS WITH LOW
LITERACY, NUMERACY, AND PROBLEM
SOLVING SKILLS?
HEALTH LITERACY IS ESSENTIAL

 Four greatest ineffeciencies in the health care

system:
 Compliance

 Hospital readmissions
 Over-testing

 Unnecessary emergency room visits

Effective Communication is Absolutely Critical

 QUIZ

 Of the following domains, which is the stronger

predictor of heath?
 Literacy

 Numeracy

 Problem-solving in technology rich environments

UNDERSTANDING HEALTH INFORMATION
SEEKING BEHAVIORS OF ADULTS WITH LNPS
Research questions:
 What sources do people with below-average LNPS utilize when
seeking health information?

 Which of the following factors predict different health information

sources for people with below average LNPS?
 Gender
 Age
 Race
 Educational Attainment
 Health Status
 Use of Preventive Measures
 Facility in English

From Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.
USE OF HEALTH INFORMATION BY COGNITIVE
DOMAIN

From Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.
PREDICTING USE OF HEALTH INFORMATION
Print Media Internet Radio / TV Social Health
Professional
Gender Female Female Female Female
Age Older Younger Middle Older
Race BAH HA BH B
Education HS HS
Health Good Good Good Good Good
Status
Preventive + + + +
Reading High High High
Writing High High High
Speaking

Adapted from Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.
KEY FINDINGS
 One size doesn’t fit all. People with low level literacy, numeracy, and
problem solving skills who seek health information report having
better health status than those who do not seek health information.
 People with low level LNPS report that oral sources of communication
are used more than written sources.
 Low literacy and numeracy seek information from radio/TV whereas
those with low problem solving skills use the internet and health
professionals.
 Having high facility in writing English is a significant predictor of using
the Internet and Health professionals as a source of health
information for those with low LNPS.
 Having a HS diploma is significant only when seeking health
information through the Internet or print media.

Fom Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.
IMPLICATIONS
 Different stakeholders have unique roles to play in
increasing health information seeking behaviors.
 Develop more focus and skills in oral participatory care with
patients and care givers
 The health care industry could simplify / standardize forms
and written materials
 Policy makers could include health literacy at appropriate
funding levels for K-12 and Adult Basic Education curricula
 Health educators and researchers must develop
interventions to address health information seeking
behaviors through differing skill levels in multiple modalities.

From Health Information Seeking Behaviors in Adults with Below Average Literacy, Numeracy, and Problem Solving Skills.
POLICY IMPLICATIONS
 “Making Skills Everyone’s Business”
 Create joint ownership of solutions
 Expand opportunities for adults to improve foundation skills
 Make career pathways available and accessible in every
community
 Ensure students have access to highly effective, teachers,
programs, leaders
 Align federal policies to integrate services for adults
 Increase the ROI in skills training for business, industry, and
labor
 Commit to closing the equity gap for vulnerable sub-
populations
STRATEGIES FOR PRACTICE
 Find commonality in what we say. For example:
 Sugars
 Blood sugar
 A1c
 Blood too sweet
 Diabetes
 Diabetic counts
 Sugar counts

 Or:
 High blood pressure
 Hypertension
 Pressures
 Blood pressure
 Systolic and dialostic
NARRATIVE ANIMATION
In this example from
Dartmouth-Hitchcock,
patients not only increased
their knowledge of
colonoscopy procedures,
they also had:
 Experienced decreased
anxiety
 Lower doses of sedation
medication
 Shorter procedure times
OR A FAVORITE “TEACH BACK” MOMENT?

From House MD, on YouTube:

https://www.youtube.com/watch?v=nvwR74XpKUM
YOUR TURN
 What kind of educational resources or strategies do you use
with your clients/patients who have low LNPS?
 Have you noticed a difference in whether it helps them? If
so, how do you know? (anecdotal or otherwise).
 Describe it to the person next to you.
 Write your idea on the 4x6 notecard. Include:
 Name
 Email / phone
 Pass the cards to the right, then pass them forward.
 Strategies shared will be posted to:
http://bit.ly/HealthLiteracySummit
RESOURCES
 PIAAC Gateway: http://piaacgateway.com/
 Making Skills Everyone’s Business: A Call to Transform Adult Learning
in the United States:
http://www2.ed.gov/about/offices/list/ovae/pi/AdultEd/making-
skills.pdf
 NCES: http://nces.ed.gov/surveys/piaac
 https://animoto.com/play/vkcbVNuie4iIEblsjwBXKw
 Webinar: Health Literacy Through the PIAAC Lens, May 4 at 3:00 pm
ET www.national-coalition-literacy.org
 LINCS Health Literacy Collections and Online Community of Practice:
https://community.lincs.ed.gov/
 World Education’s Health Literacy Special Collection:
http://www.healthliteracy.worlded.org/
 Health Literacy Discussion List:
http://listserv.ihahealthliteracy.org/scripts/wa.exe?INDEX
THANK YOU!
 National Center for Education Statistics
 Organisation for Economic Co-operation and
Development
 American Institutes for Research
 World Education
 Georgia State University
 Portland State University

Questions? Jackie Taylor, Jackie@jataylor.net

EVERYTHING AFTER THIS ARE SPARE SLIDES IN
CASE NEEDED
PIAAC PROVIDES A RICH SOURCE OF DATA THAT
TELLS US:
 What skills adults actually have and can use rather
than just the number of years of education they have
completed or the degrees they have.
 How adults acquire those skills, and what factors are
related to skill acquisition and decline.
 What the level and distribution of skills is within and
across various subgroups within the population.
 As a result. PIAAC data enables us to target our efforts
to focus on raising the skills of adults with the greatest
needs.

40
HEALTH LITERACY IN THE UNITED STATES
Answer: 12%
Adults Self-Rated Health Status and 2012
PIAAC Average Literacy Scores

Note: Total possible score is 500. *p<.05. Average score is significantly different from “Excellent” average.
Source: U.S. Department of Education, National Center for Education Statistics. 2013. Literacy, Numeracy, and Problem
Solving in Technology-Rich Environments Among U.S. Adults. Washington, DC.
A NATIONALLY REPRESENTATIVE SAMPLE OF HOUSEHOLDS IN
EVERY COUNTRY

 In the U.S. the household sample was selected through a 4-stage

stratified area sample:
 Counties (PSUs)
 Blocks
 Housing units with households
 Eligible persons within households
 Resulted in 5,010 respondents
 A U.S. supplement will add 3,600 more adults (report due late
2015) that represent key populations (young adults 16-34 yrs,
older adults 66-74 yrs, unemployed adults,16-65 yrs)
 A representative prison sample will include 1,200 inmates, 16-74
yrs, in state, federal and private prisons (report due 2016).

42
PIAAC BACKGROUND QUESTIONNAIRE
Focused on identifying:
 Skills that are critical to functioning successfully in today’s society,
 How participants acquire those skills, and
 How those skills are distributed.

Areas of BQ include:
 Education and training, present and past,
 Work experience,
 Literacy, numeracy and ICT skill use at work and at home,
 Other 21st century skills used at work,
 Personal traits, and background information.

PPT slide provided courtesy of AIR

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U.S. CHANGES INCLUDE:

• Additions
• Basic skills training
• Political Efficacy - Information
• Health
Background questionnaire • Race/Ethnicity
• Language
• Adaptations:
• Formal Education, Informal
5 min Training
• Occupation, Economic Sector,
Earnings

PPT slide provided courtesy of AIR

 THESE DESCRIPTIONS OF THE PIAAC PROFICIENCY
LEVELS FOR LITERACY DEFINE WHAT ADULTS CAN DO
AT EACH LEVEL.
Level 5
Level 4 (376-500)
Level 3 (326-375)
Integrate
Level 2 (276-325) Perform information
Level 1 (226-275) across
Below Identify, multiple-step
(176-225) multiple,
Level 1 interpret, or operations to
(0-175) Make matches integrate, dense texts;
evaluate
construct
Read between text one or more interpret, or
relatively and synthesize syntheses,
Locate pieces of
ideas or
single piece short information information information
digital, that may from points of
of and often
print or require low complex view; or
information require
mixed level para- texts, and evaluate
in familiar varying
texts to phrasing and may require evidence
texts. levels of
locate drawing low- complex based
inference.
single text. level inferences. arguments.
inferences.

PPT slide provided courtesy of AIR

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 THESE DESCRIPTIONS OF THE PIAAC PROFICIENCY
LEVELS FOR NUMERACY DEFINE WHAT ADULTS CAN
DO AT EACH LEVEL.
Level 5
Level 4 (376-500)
(326-375)
Level 3 Understand
Level 2 (276-325) Perform complex
(226-275) analysis, abstract
Level 1 Understand complex mathema-
Below tical and
(176-225) & work with reasoning,
Level 1 (0- Perform 2 or statistical
more mathematical statistics and
175) patterns, ideas,
Perform one- calculations, chance;
proportions, spatial embedded
step tasks: simple in complex
Perform measurement; basic relationships;
count; sort; texts, draw
basic tasks: spatial statistics and
arithmetic inferences;
counting, representation; expressed in communica-
operations; arguments
arithmetic
understanding estimation; and verbal or ting well-
or models;
operations
simple percent interpret simple numerical reasoned
justify,
with whole tables, graphs. form. explanations
(ex. 50%). reflect on
numbers. for answers.
solutions or
choices.
PPT slide provided courtesy of AIR
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These descriptions of the PIAAC proficiency levels
for digital problem solving define what adults
can do at each level.
Level 3
(341-500)
Level 2
(291-340) Task may involve
Level 1
multiple steps
(241-290) and operators,
Below Level 1 Tasks require
some navigation navigation across
(0-240) pages and
Tasks require across pages and
little or no applications for applications.
navigation, and solving the There are
Tasks are well-
only a few steps problem. typically high
defined
to access Evaluating the monitoring
involving use
information for relevance, some demands, and
of only one
solving the integration and evaluation of
function within
problem. There inferential relevance and
a generic
are few reasoning may be reliability of
interface.
monitoring needed. information.
demands.
PPT slide provided courtesy of AIR
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THE U.S. AVERAGE LITERACY SCORE (270) WAS
LOWER THAN THE INTERNATIONAL AVERAGE (273).
Literacy
Japan
Finland
Netherlands • Scores on literacy ranged from 296
Australia
Sweden (Japan) to 250 (Italy)
Norway
Estonia
Flanders-Belgium
Czech Rep. • U.S. scores were:
Slovak Rep.
Canada
Korea, Rep. of
• Lower than in 12 countries
U.K.
Denmark
• Not significantly different than
Germany
United States in 5 countries
Austria
Cyprus • Higher than in 5 countries
Poland
Ireland
France
Spain
Italy

48
PPT slide provided courtesy of AIR
THE U.S. AVERAGE NUMERACY SCORE (253) WAS
ALSO LOWER THAN THE INTERNATIONAL AVERAGE
(269).
Numeracy
Japan
Finland
Flanders-Belgium
Netherlands
• Numeracy scores ranged from
Sweden
Norway
288 (Japan) to 246 (Spain)
Denmark
Slovak Rep.
Czech Rep.
Austria • U.S. scores were:
Estonia
Germany • Lower than in 18 countries
Australia
Canada • Not significantly different than
Cyprus
Korea, Rep. of
U.K.
in 2 countries
Poland
Ireland
• Higher than in 2 countries
France
United States
Italy
Spain

PPT slide provided courtesy of AIR

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THE U.S. AVERAGE SCORE IN DIGITAL PROBLEM
SOLVING* (277) WAS ALSO LOWER THAN THE
INTERNATIONAL
PS-TRE
AVERAGE (283).
Japan
Finland
• Italy, Spain, Cyprus and France did
Australia
Sweden
not include this domain in their
Norway
Netherlands
assessment
Austria
Denmark • Scores ranged from 294 (Japan) to
Czech Rep.
Korea, Rep. of 275 (Poland)
• U.S. scores were:
Germany
Canada
Slovak Rep.
Flanders-Belgium • Lower than in 14 countries
U.K.
Estonia
United States
• Not significantly different than in 4
Ireland
Poland
other countries
Italy
Spain • Higher than no other country (Italy,
Cyprus
France Spain, Cyprus and France did not participate)
* Officially problem solving in technology-rich environments (PS-TRE) 50
THE DIRECT ASSESSMENT FOCUSES ON FOUR
DOMAINS:
 Literacy: both paper & pencil and computer versions
 Numeracy: both paper & pencil and computer versions
 Problem solving in technology-rich environments: only on
computer
 Reading components: only paper & pencil
 All countries were required to administer literacy and
numeracy assessments
 The U.S. assessed all four domains

PPT slide provided courtesy of AIR

51
A HIGHER PROPORTION OF U.S. ADULTS ARE
ALSO AT THE LOWEST LEVELS OF DIGITAL
PROBLEM SOLVING.

PPT slide provided courtesy of AIR

AN EVEN HIGHER PROPORTION OF U.S. ADULTS ARE
AT THE LOWEST LEVELS (LEVEL 1 AND BELOW LEVEL
1) OF NUMERACY.

PPT slide provided courtesy of AIR

HEALTH STATUS / INSURANCE QUESTIONS
 In general, would you say that your health is
excellent, very good, good, fair, or poor?
 Do you have any difficulty seeing the words and
letters in ordinary newspaper print, even when
wearing glasses or contact lenses if you usually
wear them?
 Have you ever been diagnosed or identified as
having a learning disability?
 Do you have any kind of medical insurance or are
you enrolled in any kind of program that helps you
pay for your health care?
SOURCES OF INFORMATION / PREVENTIVE
MEASURES
 How much (a lot, a little, some, or none) information about
health issues do you get from...newspapers, magazines,
Internet,
 Radio
 TV
 Books or brochures
 Family, friends, or coworkers?
 Talking to health care professionals such as doctors, nurses,
therapists, or psychologists?

 In the past year, have you:

 Gotten a flu shot?
 Had your vision checked?
 Visited a dentist?
THE DIRECT ASSESSMENT FOCUSES ON FOUR
DOMAINS:
 Literacy: both paper & pencil and computer versions
 Numeracy: both paper & pencil and computer versions
 Problem solving in technology-rich environments: only on
computer
 Reading components: only paper & pencil
 All countries were required to administer literacy and
numeracy assessments
 The U.S. assessed all four domains

PPT slide provided courtesy of AIR

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