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
PIAAC assessment 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 In the U.S., 80% took the computer
computer or tests and 15% took the paper-and-
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
was English or Spanish. About 4% could not
conducted complete the BQ because of language
only in difficulties or learning or mental disabilities,
English in the and 1% could not complete it for other
U.S.: 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

8
HOW PIAAC COLLECTS DATA

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

PPT slide provided courtesy of AIR

9
 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
learning and updating
skills
professional skills
use of gross
and
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

11
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
31
33
30 28
25 24

20 17
15
15
11 International Average
10
United States
5 4 4

0
 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

270 United States

Good
262 International
Average
254
Fair/Poor
242

220230240250260270280290
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 United States

Good
246 International
Average

247
Fair/Poor
220

0 50 100 150 200 250 300

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 Numerac PS-TRE
Japan
Finland
y
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
environments.
Spain Italy Cyprus
Italy Spain France

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 Internet Radio / Social Health

Media TV 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
Preventiv + + + +
e
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-
Level 3 (326- 500)
Level 2 (276- 375)
Level 1 (226- 325)
Below
(176- 275)
Level
225)
1 (0-
175)

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
Level 2 (276-325)
(226-275)
Below Level 1
Level 1 (176-225)
(0-175)

PPT slide provided courtesy of AIR

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levels for digital problem solving define what
adults
can do at each level.
Level 3
(341-500)
Level 2
(291-340)
Level 1
(241-290)
Below Level
1 (0-240)

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
(Japan) to 250 (Italy)
Australia
Sweden
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).
Numerac
y
Japan
Finland
Flanders-Belgium
Netherlands
• Numeracy scores ranged
Sweden
Norway
from 288 (Japan) to 246
Denmark
Slovak Rep. (Spain)
Czech Rep.
Austria
Estonia
Germany • U.S. scores were:
• Lower than in 18
Australia
Canada
Cyprus
Korea, Rep. of
U.K.
countries
Poland
Ireland
• Not significantly different
France
United States than in 2 countries
Italy
Spain • Higher than in 2 countries
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 not
Australia
Sweden
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,
Spain, Cyprus and France did not participate)
Cyprus
France

* Officially problem solving in technology-rich environments (PS-

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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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