Health Literacy Skills of U.S. Adults by baassou1995


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									Health Literacy Skills of U.S. Adults
Rima E. Rudd, MSPH, ScD

   Objectives: To examine adults’                 restrictions, with limited access
literacy proficiencies in multiple                to resources, who are members of
health contexts. Methods: One                     minority population groups, and
hundred ninety-one (191) health-                  who are immigrants – have lower
related items drawn from all large-               health literacy skills than do oth-
scale adult literacy surveys be-                  ers. Conclusions: The distribu-
fore 2003 were scored as an inde-                 tion of health literacy is not inde-
pendent health literacy scale. La-                pendent of general literacy skills
tent class analyses provide por-                  at population or subpopulation lev-
traits of adults with different                   els.
health literacy skills. Results:                    Key word: health literacy
Adults without a high school di-                     Am J Health Behav. 2007;31(Suppl
ploma or GED, with health-related                 1):S8-S18

    n 1993 and again in 2005, the portraits       graduate. In addition, close to 100 studies
    of adult literacy proficiencies that          show a relationship between reading
    emerged from the National Center for          skills of adults and a variety of health
Education Statistics were met with shock          activities and health outcomes.1-3
and dismay. These surveys indicate that               Recent seminal reports from the US
approximately half of US adults lack the          Department of Health and Human Ser-
literacy skills needed for full participa-        vices, 4 the Agency for Healthcare Re-
tion in the current economy and for the           search and Quality,2 and the Institute of
demands of everyday life in an industrial-        Medicine5 (IOM) have provided reviews
ized nation. Although both reports note           and commentary on issues and study
that illiteracy is rare in the United States,     findings in the emerging area of inquiry
findings indicate that large numbers of           that has come to be known as health
adults in the United States have difficulty       literacy. The IOM report, offering the most
using, with accuracy and consistency,             detailed analysis of health literacy in the
the many complex print materials found            United States to date, called for the devel-
in everyday life and needed for routine           opment of new measures of health lit-
tasks. Well over 800 studies published            eracy that went beyond approximations of
over the past 2 and a half decades indicate       reading skills to more accurately reflect a
that many health materials are written            full array of literacy skills – reading, writ-
at reading grade levels that exceed the           ing, oral presentation, aural comprehen-
reading skills of an average high school          sion, and basic mathematical computa-
                                                      The primary objective of the study de-
                                                  scribed herein was to provide an analysis
   Rima E. Rudd, Senior Lecturer on Society,      of health literacy skills among US adults
Human Development, and Health, Department of      based on an understanding of literacy as
Society, Human Development and Health, Harvard
School of Public Health, Boston MA.
                                                  a set of functional skills, measured by
   Address correspondence to Dr Rudd, Depart-     one’s ability to use print materials to
ment of Society, Human Development and Health,    accomplish everyday health tasks. In or-
Harvard School of Public Health, 677 Huntington   der to conduct such an analysis, a derived
Avenue,     Boston     MA    02115.    E-mail:    assessment of health literacy was con-                            ducted based on the most prominent na-


tional and international surveys of adult         goals, and to develop one’s knowledge
literacy proficiencies. The study began           and potential.11
with the development of a health activi-
ties framework based on a range of health          The measures of adult literacy are
contexts, including but not limited to          based on the premise that adults do not
health care settings. A secondary objec-        read printed or written materials in a
tive was to offer baseline data of US adult     vacuum but instead turn to materials for
health literacy proficiencies in multiple       a specific purpose. The education schol-
health contexts. Study findings offer a         ars who crafted these surveys focused on
comprehensive portrait of health literacy       people’s ability to use print materials
among US adults. Overall, the study pro-        commonly found in everyday life to ac-
cess and, particularly, the analysis of         complish mundane tasks. Efforts were
health tasks offer insight for the develop-     made to select a broad range of materials
ment of intervention studies.                   within a wide range of relevant contexts
                                                and contents and avoid specialized mate-
    METHODS                                     rials familiar only to particular groups.
    The study is based on a health activi-      Thus, materials for the various large-
ties typology that includes health promo-       scale adult literacy surveys were drawn
tion, health protection, disease preven-        from 6 domains of everyday life: home and
tion, health care and disease manage-           family, health and safety, community and
ment, and systems navigation. Research-         citizenship, consumer economics, and
ers, versed in the typology of health ac-       work, as well as leisure and recreation.
tivities, examined and analyzed all items          The materials used in the surveys
on all large-scale adult literacy surveys       varied by type and consisted of prose and
conducted before 2003. These surveys            documents, as well as both continuous
included the 1986 assessment of the             and noncontinuous texts requiring 1 or
nation’s young population,6 the 1990 as-        more arithmetic operations. For example,
sessment of America’s job seekers by the        materials included a newspaper article
US Department of Labor,7 the 1992 Na-           (continuous text), a weather chart (docu-
tional Adult Literacy Survey,8 and the          ment), a work benefit package (continu-
International Adult Literacy Surveys that       ous text), as well as a bank deposit slip (a
were conducted over 3 cycles involving          table) and an advertisement for a 10% off
more than 20 countries and language             sale at a supermarket (text with num-
groups.9,10                                     bers). The tasks were organized into 3
    All items in the surveys were coded as      major categories—locate information,
health or as non-health related as part of      integrate information, and generate in-
what is later referred to as the Health         formation—and were designed to simu-
Activities Literacy Study (HALS). Over          late the specific tasks that people com-
230 health-related items were distilled         monly undertake in daily life.11 Prose,
from the surveys and coded as belonging         document, and quantitative literacy as
to 1 of 5 categories of health activities, as   well as the associated texts and tasks are
noted above. Of these, 191 were used in         described in more detail in Table 1.
US surveys. These 191 health activities            All of the adult literacy surveys were
and literacy items were constructed as a        constructed around everyday materials
health literacy scale for US analyses. We       focused on everyday types of tasks. An
turn first to the features of the adult         adult with asthma may use a weather
literacy surveys and then to the coding         report to make decision about the day’s
process and the characteristics of the          activities. A parent may consult a chart
health literacy scale.                          on a package of over-the-counter medi-
                                                cine to determine correct dosage for a
  Characteristics of Health Items on            child of a specific age or weight. A worker
  Adult Literacy Surveys                        may need to use a pay stub to locate
  The study of adult health literacy builds     information needed on an insurance ap-
on the national and international sur-          plication. The example provided in Figure
veys of adult literacy, all of which adopted    1 is taken from a label on an over-the-
the same functional definition of literacy:     counter pediatric medicine, in use in the
                                                1990s. This material has component parts
  Using printed and written information         in prose and document format, and it also
  to function in society, to achieve one’s      contains numbers. It provides a good il-

Am J Health Behav.™ 2007;31(Suppl 1):S8-S18                                              S9
Health Literacy in the U.S.

                                            Table 1
                                   Literacy Texts and Tasks
  Literacy                              Examples of
  Type         Description              Text Types                         Tasks

  Prose        Knowledge and            Editorials, news stories, poems,   The prose tasks associated
               skills needed to read    and fiction. These texts types     with these texts include finding
               and understand           vary and include descriptive,      a piece of information in a
               materials that are       expository, argumentative,         newspaper article, interpreting
               formed of sentences      and instructive types.             instructions from a warranty,
               organized into                                              inferring a theme from a poem,
               paragraphs.                                                 or identifying the contrasting
                                                                           views expressed in an editorial.

  Document     Knowledge and skills     Tables, charts, graphs, maps,      Tasks associated with the use
               required to locate and   and forms. These texts include     of documents include using a
               to use information       maps, job applications,            chart to determine the correct
               contained                transportation schedules and       dosage of medicine based on
                                        payroll forms.                     age and weight, using a schedule
                                                                           to choose the appropriate bus,
                                                                           or entering information on an
                                                                           application form.

  QuantitativeKnowledge and             Use of numbers embedded in         Tasks require one or more
              skills needed to be       print materials formatted as       arithmetic procedures based on
              able to apply             either prose or document texts.    information in the text.
              arithmetic operations,                                       Examples of tasks include
              either alone or                                              balancing a checkbook,
              sequentially.                                                figuring out a tip, completing an
                                                                           order form, or determining the
                                                                           amount of interest from a loan

lustration of different types of tasks at                 ucts, using products at home or at work,
varying levels and is discussed, in detail,               interpreting information about air and
in Literacy and Health in America.12                      water quality, using medicine, applying
   The final set of items and scoring for                 for insurance, and offering informed con-
the HALS adapted the format and struc-                    sent. Table 2 provides a list of these
ture of the National Adult Literacy Survey                categories with selected examples of
(NALS) of 1992, which was conducted with                  materials and tasks. Trained research
a sample of 26,091 adults age 16 and                      assistants independently coded all mate-
older.8 Scores for the NALS and the other                 rials and questions. All differences were
large-scale surveys from which the health                 resolved through discussions and refine-
items were drawn ranged from 0 to 500                     ment of the coding criteria.
and were characterized in terms of 5                         In all, 191 literacy tasks were judged to
levels, used to represent the progression                 measure health-related activities across
of complexity and difficulty of the tasks                 U.S. surveys. Those items used only on
along the literacy scales. The authors                    the International Adult Literacy Survey
used the same scale, range, and levels for                (IALS) or only on the Adult Literacy and
the HALS analysis.12                                      Learning Survey (ALLS) were not included.
                                                             The coded items represent important
   Health-related Materials and Tasks                     aspects of health literacy across the 5
   The organizing framework used for the                  contexts; 60 items addressed health pro-
coding and analysis spans various health                  motion, 65 were on health protection, 18
tasks such as purchasing food and prod-                   items were on disease prevention, 16


                                     Figure 1
                             Pediatric Medicine Label

concerned health care and disease man-        However, because the focus of this in-
agement, and 32 items addressed naviga-       quiry was the US adult population, the
tion. Health promotion and health protec-     health activities literacy study used only
tion items constitute the bulk of the items   population samples from the United
(n=125). Only 66 of the items [activities     States.
under prevention, care and management,           The procedure to align the health lit-
and navigation] represent activities re-      eracy activities scores with the NALS was
lated to health care settings. Thus, the      based on matching 2 moments of the
set of 191 items was not distributed evenly   proficiency distributions – the mean and
across each of the 5 health activities.       standard deviation. The link between
   The psychometric behavior of each item     HALS and NALS contributes to the valida-
was checked as was the fit of each item       tion of the HALS, and correlations were
into the overall scale used for the HALS      examined between HALS and a wide range
analysis. More than 58,000 respondents        of background characteristics that in-
from across the various adult surveys         clude age, gender, race/ethnicity, level of
were used to estimate and verify the          education, country of birth, health status,
health-related literacy item parameters.      and wealth. Final HALS scores are pro-

Am J Health Behav.™ 2007;31(Suppl 1):S8-S18                                          S11
Health Literacy in the U.S.

                                  Table 2
           Health Activities Framework With Selected Examples
  Activities         Content Focus        Examples of Materials             Examples of Tasks

  Health Promotion Enhance &              Articles in newspapers and        Purchase drinks with low
                   maintain health        magazines, booklets,              sugar content
                                          brochures, charts, graphs,        Plan exercise daily regimen
                                          lists, food and product labels

  Health             Safeguard health     Articles in newspapers and        Decide among product
  Protection         of individuals &     magazines, postings for health    options
                     communities          and safety warnings at work       Follow safety precautions
                                          or in the community, air and      Vote
                                          water quality reports,

  Disease            Take preventive      News alerts [TV, radio,           Determine risk
  Prevention         measures & engage    papers], postings for inocula-    Engage in screening or
                     in early detection   tions & screening, letters with   diagnostic tests
                                          test results, graphs, charts      Purchase food with low
                                                                            Make a follow-up

  Health Care        Seek care & form a   Health history forms, medicine    Describe & measure
  & Maintenance      partnership with     labels, discharge instructions,   symptoms
                     health providers     education booklets & brochures    Follow directions on medicine
                                                                            Calculate timing for medicine.

  Systems            Access needed        Maps, Application forms,          Locate facilities,
  Navigation         services             statements of rights and          Apply for benefits
                     Understand rights    responsibilities, informed        Offer informed consent
                                          consent, benefit packages

vided as a composite score of prose, docu-            There is no significant difference between
ment, and quantitative literacy.                      men (average score of 272) and women
                                                      (average score of 271) on the HALS.
    RESULTS                                              An additional 27% of adults are esti-
    The average overall score of 272 (with a          mated to be performing in Level 2 on the
standard deviation of 61) on the HALS is              HALS. Together, some 46% of the adult
similar to the average scores on the 3                population (levels 1 and 2 combined) is
literacy scales reported in the NALS. Fig-            estimated to have restricted health lit-
ure 2 provides an illustration of HALS                eracy proficiencies in that they are per-
proficiencies, overall and by gender. There           forming below the average proficiencies of
is little illiteracy in the United States. How-       adults who terminated their education with
ever, 19% of the adult population performs            a high school diploma or GED. As is illus-
in the lowest of the 5 levels on the HALS,            trated in Figure 3, adults who have not
indicating difficulty using relatively simple         completed high school or earned a GED
texts. Of these, 7% are estimated to be               have an average score on the HALS of 220,
performing at the bottom of this level and            or at the upper end of Level 1. Those who
thus are unable to perform even simple                either graduated from high school or earned
tasks with a high degree of proficiency.              their GED achieved an average score of


                                                             Figure 2
                                               Overall HALS Findings and by Gender

                                               36                                                        36

                                                                                                    29                 HALS Levels
    Percentage in Level

                                          27                          26
                          20                                                                                                2
                                                    17                                                        16
                                     12                          12
                          10                                 8
                                 7                                                         7                                5

                                                         1                           1                             1
                               Total Population (272)            Male (272)                    Female (271)

271; those who continued their education                                             the United States is 278 compared to the
beyond high school obtained an average                                               overall average of 272. HALS proficiency
score 306 and those who continued their                                              scores among non-native-born adults are
education beyond high school obtained an                                             significantly below that of the native-born
average score of 306.                                                                adult population. The average proficiency
   Differences in proficiency scores by                                              of European Americans (white) on the
age were evident as well. The average                                                HALS is significantly higher than are the
health-related skills of younger popula-                                             average proficiency of African Americans
tions are significantly higher than those                                            (black), Hispanic Americans, and other
of older adults. Those over the age of 65                                            groupings of adults living in the United
have an average HALS score of 224 com-                                               States. African American adults have an
pared to 287 for those 30-45 years of age                                            average HALS score of 239 and Hispanic
and 282 for those 16-29. However, HALS                                               American adults have an average of 217.
scores differ among older adults based on                                            However, among Hispanic American
education, health status, and wealth.                                                adults born in the United States, the
Table 3 provides an overview of HALS                                                 average HALS score is 256.
proficiency among older adults by selected                                              Findings indicate that adults with lim-
characteristics. Older adults with educa-                                            ited health literacy proficiencies are gen-
tional achievement beyond high school                                                erally those who have not completed high
level and with access to resources have                                              school or obtained a GED, have health-
higher literacy skills than do those with-                                           related restrictions on their ability to
out such background or resources.                                                    attend school or work, are members of
   When nativity is considered, the aver-                                            minority or marginalized population
age HALS proficiency for adults born in                                              groups, and/or who have immigrated to

Am J Health Behav.™ 2007;31(Suppl 1):S8-S18                                                                                          S13
Health Literacy in the U.S.

                                                   Figure 3
                                 HALS Proficiencies by Educational Attainment


                                                                              42                           43

                            40                                                                                           HALS Levels
                                                                                                                34           <1
      Percentage in Level

                            30        26                                                                                     2
                                 22                                                                                          3
                            20                  17                                                    17                     4
                            10                                                     8

                                                     2          3                                 3                  3
                                                         0.5                           0.5    1
                                  Less than High               High School or GED Beyond High School
                                 School (Mean 220)                 (Mean 271)         (Mean 306)

the United States. Furthermore, those                                                  eracy report recommends a broad under-
with limited health literacy proficiencies                                             standing of when and where adults take
are likely to report living in poverty with                                            action related to their health. Attention
no income from savings, dividends, or                                                  to multiple health contexts moves beyond
retirement. Table 4 provides an overview                                               a vision of adults as patients and consid-
of mean HALS proficiency by wealth sta-                                                ers a full spectrum of health-related ac-
tus and level of education. Latent class                                               tivities of daily life.
analyses yielded portraits of groups of                                                   The study findings offer an initial ex-
adults who are likely to have limited                                                  amination of health literacy proficiency
health literacy proficiency. Adults with                                               that moves beyond assessments of mate-
limited health literacy proficiencies are                                              rials, word recognition skills, or reading
more likely to report reading little prose                                             comprehension. The analysis of health
and no documents and are more likely to                                                literacy proficiencies indicates that the
rely on television as a primary source of                                              distribution of health literacy is not inde-
information than are adults with higher                                                pendent of general literacy skills at a
scores.12                                                                              population or subpopulation level. Al-
                                                                                       though there is clearly some unique pro-
   CONCLUSIONS                                                                         cedural and declarative knowledge that is
   The analysis presented here is based                                                needed to function in health contexts,
on the 191 health-related tasks used                                                   those with more general literacy skills
across several literacy surveys, ranging                                               will also be more likely to have stronger
from simple to complex, and representing                                               health literacy skills.
tasks undertaken in each of 5 health
activities delineated in the health lit-                                                 DISCUSSION
eracy framework. The IOM health lit-                                                     Expectations of and literacy-related


                Table 3                                   Table 4
        HALS Proficiency Among                   HALS Proficiency by Wealth
        Older Adults by Selected                       and Education
                                                                     HS <    HS/GED >HS
  Characteristics of Adults   Mean   SD                              Mean    Mean   Mean
                                                                     Score   Score  Score
  >65                         224    60
                                                Working adults
  By Education Level                            [with assets]        273     291    321
     Less than High School    192    54
     High School or GED       240    44         Working adults
     Beyond High School       268    45         [without
                                                additional assets]   218     267    293
  By Health Status
    Limiting condition        198    57         Elders
    No limiting condition     236    57         [with assets]        216     257    285

  By Poverty Status                             [without assets]     217     264    281
     Poor/Near Poor           193    55
     Not Poor                 242    54         Elders
                                                [in poverty
  By Whether They                               without assets]      188     240    261
  Receive Dividends
     No                       210    57
     Yes                      256    51
                                              were collected as part of a sample of ma-
                                              terials gathered to represent various do-
                                              mains of everyday life. A thorough analy-
demands on the US adult population are        sis and coding of all health-related items
increasing in all sectors, including the      supported an investigation into health
health sector. This increase in demands       literacy skills.
is associated with the diffusion of infor-        The more recent 2003 NAAL included a
mation and communication technologies         purposive sample of materials and items
and with an increased expectation that        related to health. The US Department of
individuals need to accept more responsi-     Health and Human Services worked with
bility for acquiring and using information    the Department of Education to insert a
related to many aspects of their lives.       number of specific health related items to
Unfortunately, in face of these increases     be analyzed independently and so serve
in demands and expectations, the find-        as a measure of progress for the health
ings from the 2003 National Assessment        literacy objective in Healthy People 2010
of Adult Literacy (NAAL) indicate there       and subsequent years. Consequently, 28
has been little improvement of adult skills   new items related to 3 domains of health
over time — from the first national survey    and health care information and services
of adult literacy skills in 1992 to that      were added to the literacy assessment
conducted during the first decade in the      tool. These items represented 3 domains
new century. Instead, evidence points to      labeled clinical, prevention, and naviga-
lower proficiencies.13                        tion of the health care system. Each of the
                                              28 items followed the same format and
  Comparison Between HALS and NAAL            structure of other materials and tasks on
  Health Literacy Report                      the literacy tool as discussed earlier and
  The examination of all items from the       so included prose, document, and quanti-
NALS and other large-scale literacy sur-      tative items.14 Although the 2 analyses
veys enabled the authors to identify a        are not directly comparable, they are based
wide range of health-related materials        on the same conceptualization of func-
and tasks. The health-related materials       tional literacy and the same structure of

Am J Health Behav.™ 2007;31(Suppl 1):S8-S18                                                 S15
Health Literacy in the U.S.

materials and tasks.                           lower than those for general literacy
    In addition, several changes were made     among adults as measured by the NAAL14
in the analytic processes for the 2003         and the average scores for the HALS. In
NAAL data. These changes were related          2006, the conclusion remains the same:
to the sampling parameter, to the perfor-      large numbers of US adults do not have
mance levels used to identify and charac-      health literacy skills that would enable
terize the participants, and in the level      them to effectively use complex health
set for the probability of doing a task        materials to accomplish challenging or
correctly. In brief, the analysis of the       complex health-related literacy tasks.
NAAL data does not include 3% of the
population who were unable to answer a             Insights
background questionnaire because of in-            The adult education sector’s focus on
ability to read in English or in Spanish or    proficiencies related to the use of materi-
because of a mental disability. Next, new      als to accomplish health-related tasks
performance levels, deemed more appro-         offers insight to those of us concerned
priate and useful for education policy were    with health literacy. First, the adult lit-
used instead of the NALS 1 through 5           eracy surveys bring our attention to the
levels. The new levels are labeled below       many different types of health-related
basic, basic, intermediate, and proficient.    texts developed for adults and to the char-
These labels were developed to help adult      acteristics of texts that enhance or im-
education policy makers to identify per-       pede actual use. The format and struc-
formance levels and needed programs.           ture of different types of texts may influ-
Finally, although the NALS mapped items        ence adults’ ability to carry through with
to a performance level of 80% likelihood of    critical tasks and thereby accomplish
getting an item correct, the NAAL used         important activities.
the 67% probability convention.15 As a             Print and on-line guidebooks and a
result, a comparison of the NAAL health        variety of measurement tools offer sug-
literacy findings with the HALS findings       gestions for the development of health
published here are even more cumber-           materials designed to ease reading, com-
some. At the same time, the results of         prehension, and retrieval of information
both do indicate ongoing serious prob-         and instructions.16 The analysis of text
lems.                                          characteristics and measures of difficulty
    The National Center for Education Sta-     applied to the development of the adult
tistics announced health literacy find-        literacy surveys add further insight. Dis-
ings in September 2006. Fully 53% of US        tracting information, complex documents,
adults have health literacy scores in the      a partial provision of needed information
intermediate range, a category indicating      or instructions — all inhibit one’s ability
needed skill building. Fourteen percent of     to use print materials with ease and
adults scored at below basic level; an         accuracy.
additional 22% scored at the basic level;          Health communicators need a thor-
and 12% scored in the proficient level.        ough understanding of text characteris-
The report indicates that the average          tics in order to craft messages, develop
health literacy score for high school gradu-   information booklets, delineate proce-
ates was 232 on a 0 to 500 score range.        dures and instructions, and provide criti-
Women scored higher than men with an           cal information related to rights and con-
average health literacy score of 248 com-      sent. Formative research processes and
pared to 242 for men. Those over 65 years      procedures are well established and
of age had a health literacy mean score of     readily available to those who develop
214 (the lowest average score) compared        health materials. 17-19 Unfortunately,
to a mean score of 256 for adults between      myriad studies indicate that such in-
the age of 25 and 39 (the highest average      sights, guidelines, and research rigor are
score). The report, The Health Literacy of     often not followed or implemented for the
America’s Adults: Results from the 2003        development of health materials. Cer-
National Assessment of Adult Literacy, will    tainly, no professional ought to sign off on
be considered the baseline measure of          materials that have not undergone rigor-
health literacy 14 for measuring attain-       ous formative evaluation including re-
ment of health literacy objectives.            views and piloting with members of the
    Overall, the average scores reported for   intended audiences. In light of findings
the NAAL health literacy measure are           related to medical errors as well as to


outcomes related to limited reading abili-      powerful effects of social factors. These
ties, the health field can no longer toler-     findings set a foundation for future exami-
ate casually or carelessly written materi-      nations of literacy and health literacy as a
als and documents.                              mediating factor in health disparities.
   Adults trying to apply health informa-          Finally, this analysis indicates that
tion would benefit from clear and straight-     increases in health may be linked to a
forward written and oral communication          stronger investment in education, most
and from improvements in the design of          especially in poor and disadvantaged com-
charts and graphs. They might benefit           munities. At the same time, educational
even more if materials were designed,           opportunities for health professionals,
not only to provide information, but with       administrators, and communicators need
specific actions and tasks in mind. Mate-       to be expanded and must include a clear
rials designed from the perspective of the      understanding of health literacy, an
user, based on a clear understanding of         awareness of existing health literacy
the purpose the materials serve and the         skills among US adults, and a simulta-
tasks adults need to undertake, could           neous recognition of the very high expec-
lessen the burden on the user.                  tations and demands within our society.
   Consequently, a second valuable in-
sight emerges from the analyses of the             Acknowledgments
format and structure of the adult literacy         The author thanks Michael Wolf for his
surveys. These surveys bring our atten-         guidance and keen editing and Irwin
tion to a wide variety of mundane tasks –       Kirsch and Kentaro Yamamoto for their
those essential health tasks that cause         insight and generosity.
adults to read and use a wide range of
materials. In order to undertake an analy-      REFERENCES
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