Literacy Terms and Definitions

Definition of Terms

• Literacy is using printed and written information to function in society, meet goals, and develop knowledge, according to the National Center for Education Statistics (1993).
• NALS tasks include reading prose, interpreting documents, and quantitative computing.
• NAP defines literacy as including reading, writing, math, speech, comprehension, and numeracy.
• Numeracy is aptitude with basic probability and numerical concepts.
• Literate means able to read, write, understand, and interpret information at or above the 8th-grade level.
• Illiterate is the inability to read or write, or having reading/writing skills at or below the 4th-grade level.
• Low literacy is marginal literacy/illiteracy, with reading, writing, and comprehension between the 5th and 8th-grade levels.
• Functional illiteracy is lacking fundamental reading, writing, and comprehension skills for everyday tasks.
• Functional illiteracy also means the inability to understand and use written information as intended.
• Functional literacy is skills in reading, writing, and numeracy needed to function effectively in the community.
• Health literacy is the capacity to obtain, communicate, process, and understand basic health information and services, per the CDC in 2020.
• Health literacy involves more than just reading materials or making appointments.
• Health literacy levels change over time.
• Functional health literacy may be lower than general literacy due to "medicalese".
• Personal health literacy is the individual ability to find, understand, and use health information.
• Organizational health literacy is the ability of organizations to help individuals find, understand, and use health information.

Terms for Determining Literacy Levels

• Reading or Word recognition involves transforming letters into words and pronouncing them correctly.
• Readability is the ease of reading written information, based on language level and page layout.
• Comprehension is understanding what has been read and grasping the basic meaning.

Literacy, Instruction, and Computers

• Oral instruction alone is not very effective.
• Inoralacy is the inability to understand oral language.
• Computer literacy includes the skills to operate a computer.
• Information literacy involves the ability to assess the accuracy and validity of web sources.
• E-health literacy involves the ability to seek, find, understand, and use electronic health information.

Scope and Incidence of Illiteracy

• Illiteracy and low literacy is a silent epidemic, a silent barrier, a silent disability, and a "dirty little secret".

Key Findings on Literacy in the U.S.

• The U.S. has significant literacy problems and ranks poorly among industrialized nations.
• Low literacy is underfunded, under-researched, and largely ignored, costing about $2.2 trillion annually in economic losses.
• In 1992 NALS, 21-23% (40-44 million) were functionally illiterate, 25-28% (50 million) had very low literacy, and 46-51% (90-94 million) had low literacy overall.
• In 2003 NAAL, 43% (93 million) had basic or below basic literacy, and only 13% (28 million) were proficient.
• Low literacy is more common in minority populations, low-income groups, and older adults.
• 50% of American adults lack basic reading and numerical skills for daily life, especially in healthcare.
• PIAAC data shows many adults score at Level 2 or below, below the average of other nations.
• PIAAC data shows that Only 14% reach Levels 4/5 in literacy, and 10% in numeracy.
• PIAAC data shows that Only 5% reach the highest digital proficiency (Level 3), below the international average of 8%.
• The problem may be underestimated due to the exclusion of certain populations from surveys.

Key Issues and Implications

• Low literacy affects nearly half of U.S. adults, it limits employment, education, and health.
• Low literacy is linked to poorer health, difficulty accessing services, and economic losses.
• The issue is often neglected, with insufficient funding and research.
• Addressing it requires policy changes, better education, and awareness.
• The U.S. lags in global competitiveness due to low workforce skills.
• Reform is needed to improve productivity, health, and social mobility.
• Low literacy impacts daily tasks and societal participation and worsens healthcare access and outcomes.
• Policy action is needed for literacy programs and digital education.
• The COVID-19 pandemic highlighted the urgency of addressing global low literacy.

Those at Risk for Illiteracy

• At-risk groups include the economically disadvantaged, with 43% of adults with low literacy living in poverty.
• Older adults are at risk due to aging and sensory decline; 28% of those 65+ and 38% of those 75+ have serious hearing impairments.
• Immigrants and Non-Native English Speakers are at risk due to limited access to education and English proficiency issues, with 89% of literacy programs teaching ESL.
• Racial and Ethnic Minorities are at risk of illiteracy.
• Individuals with Low Education Levels have low high school completion rates correlating with lower literacy; in 1960, only 20% of older adults were high school graduates, compared to 88% in 2019.
• Unemployed and Incarcerated Individuals have high illiteracy rates in the prison population.
• Inner-City and Rural Residents are at risk of illiteracy.
• Also at risk are those with Chronic Mental and Physical Health Issues and Medicaid Recipients.

Key Issues

• Health Literacy: Many adults, especially older adults and minorities, struggle with medical information.
• Declining Reading skills occur because reading ability declines without practice.
• Demographic Changes: The increasing minority population in the U.S. necessitates more accessible literacy programs as the minority is projected to be over 50% by 2045.

Conclusion

• Illiteracy remains a significant problem, particularly in vulnerable groups.
• Solutions involve better education, improved access to literacy programs, and accessible healthcare communication.

Myths, Stereotypes, and Assumptions

• Illiteracy carries a stigma, leading to shame, inadequacy, fear, and low self-esteem.
• Many adults with low literacy overestimate their reading/writing abilities.
• Illiteracy is often wrongly linked to low intelligence, poor education, or specific ethnic/economic backgrounds.
• These stereotypes hinder the identification and addressing of literacy issues in healthcare.
• People rarely admit illiteracy, fearing judgment.
• Individuals use coping mechanisms like memorizing, guessing, or avoiding reading.
• Self-reporting of literacy skills is unreliable because people may overestimate their skills due to embarrassment or lack of awareness.
• Illiteracy is more common than expected; experts recommend universal literacy screening.
• Stereotypes are misleading: literacy cannot be judged by appearance, profession, or education.

The Nurse as Educators

• Nurses teach patients about health conditions, medications, and treatments.
• Effective teaching requires clear communication and awareness of patient literacy.
• Literacy affects patients understanding of health information.

Myths and Realities

• MYTH: Illiterate people are unintelligent; REALITY: Many have average or higher IQs.
• MYTH: You can spot an illiterate person; REALITY: It's often hidden, appearances are misleading.
• MYTH: More schooling = better literacy; REALITY: Years of schooling don't always equal reading ability.
• MYTH: People will admit they can't read; REALITY: They often hide it due to shame.

Assessment: Clues to Look For

• Illiteracy is hard to identify and affects all demographics with no typical pattern.
• Nurses are key to assessing literacy and educating patients because they are well-positioned to do so.
• Assumptions are risky as providers often overestimate patient literacy.
• Use "universal precautions" and assume all patients might struggle and communicate clearly.
• Patients may hide illiteracy.

Red Flags Indicating Low Literacy

• Making excuses about being too busy/tired/sick to read materials.
• Avoiding written materials or making excuses (e.g., "I forgot my glasses").
• Difficulty with forms, such as incomplete, illegible, or untouched forms.
• The patient also avoids questions.
• Camouflaging by having books/magazines around.
• Asking someone else to read for them (excuses: eye problems, lack of interest/energy).
• Nervousness about being "caught" and/or frustration/restlessness when reading.
• Examples of frustration/restlessness when reading: Mouthing/subvocalizing words, substituting words, pointing to words/phrases, and/or bewilderment.
• Incomplete/illegible/untouched registration forms.

Nurses' Frustration and the Need for Awareness

• Nurses may be frustrated by patients who seem unmotivated or non-adherent.
• Low literacy can be mistaken for pride, denial, or stubbornness.
• Misjudging patients leads to poor communication and outcomes.

Impact of Illiteracy

• A major cause of non-adherence is a lack of clear instructions.
• Reduces the ability to read, understand, and interpret instructions.
• Reduces the ability to communicate effectively.
• Reduces the ability to retain and process health information.

Cognitive and Neurological Deficiencies:

• Functional illiteracy is associated with cognitive and neurological deficits.
• Illiteracy impacts cognitive processing and brain function.
• A major problem is comprehension, or knowing words but not their meaning.
• Some need to read aloud, and others read too slowly to comprehend information.
• Memory difficulties are common.
• Low health literacy is common in vulnerable groups like low-income populations and minorities.

Illiteracy Affects Adherence:

• Non-adherence is often unintentional because patients don't understand instructions.
• Caregivers may mislabel patients as "uncooperative" or "noncompliant" due to limited comprehension.
• Almost half of adults are functionally illiterate and cannot fully understand/use written health information.
• Many providers don't consider literacy as a cause of non-adherence.

Ethical, Financial, and Legal Concerns:

• Patient Education Materials (PEMs) provide patients with written resources to educate patients.
• PEMs aid understanding of health promotion, prevention, treatments, self-care, and reinforce provider teaching.
• Problems with PEMs include that many don't consider patient literacy and are too complex due to education level, cultural and language barriers, and/or socioeconomic background.
• Low literacy increases healthcare costs due to misuse of services.
• The Joint Commission requires patient information to be understandable and culturally appropriate.
• The Patient's Bill of Rights ensures patients receive clear health information.
• Patients can forget 50% of verbal instructions quickly.
• Patient education is vital due to early discharge, decreased reimbursement, community/home care, nursing demands, treatment complexity, and the false assumption that printed information is enough.
• Research on written health materials and literacy has been limited, with basic questions to address, such as, do patients read the materials?, do they comprehend them?, are materials appropriate for the target audience?

Readability of Printed Education Materials

• There is a mismatch between patient reading levels and PEM readability.
• Public health depends on understanding food labels, OTC prescriptions, and safety warnings.
• PEMs are often written beyond the reading ability of many patients.
• Research using readability formulas shows that emergency department materials are too difficult.
• Simplified PEMs are acceptable even to sophisticated readers, especially when ill.
• Complex PEMs are ineffective if patients can't understand or won't read them.

Measurement Tools to Test Literacy Levels

• Healthcare professionals struggle to communicate complex information to patients with limited understanding.
• Nurses use PEMs heavily.
• Readability is assessed using formulas and tests that are imperfect but sufficiently related to literacy ability.

Readability Formulas for Printed Education Materials

• Readability is the characteristic of reading materials making the material easy or difficult to read.
• Readability assessment became important in the 1940s with educators seeking objective evaluation methods.
• Readability indices determine the grade-level demand of written information but don't account for individual reader variables like interest or familiarity with the topic.
• Even with similar readability levels, readers' competence varies.
• Formulas were designed for school books so they don't pinpoint every factor affecting text difficulty, so they're a helpful step, not the only measure.
• Formulas require human judgment to assess PEM quality and use mathematical equations based on writing style and reader's word recognition.
• Formulas shouldn't be the only assessment tool for effective PEM evaluation and should be chosen as formulas validated for the target reader population.

Key Formulas for Printed Education Materials

• Flesch, Fog, and Fry are strongly correlated with health literature.
• The Flesch Reading Ease (FRE) was developed in 1948 for materials from 5th grade to college and is based on average sentence length and average word length (syllables per 100 words)
• FRE is validated for news, school materials, and government publications.
• The Flesch-Kincaid (F-K) Reading Grade Level was developed for the U.S. military and is now used for legal/adult education documents.
• FRE and F-K use the same measures (word/sentence length) but with different weighting and are inversely related.
• The Fog Index was developed in 1968, is suitable for 4th grade to college, and is based on average sentence length and percentage of multisyllabic words.
• The Fog Index's simpler method is to use a 100-word sample, but the method doesn't require counting all syllables.
• The Fry Readability Graph - Extended is simple to use, accurate, covers a wide range (1st grade to college), and is used for long texts (e.g., books) by using six 100-word samples, and takes about 10 minutes to use with practice.
• SMOG was developed in 1969, is easy to compute and valid, and measures PEM readability from 4th grade to college based on polysyllabic words, with accuracy within 1.5 grades, and results that are usually about two grades higher than other methods.
• Nurses can use formulas to check if materials match the audience's literacy level to know the importance of pretesting.
• Newer measures for readability consider factors like visuals, layout, and reader characteristics.

Computerized Readability Software

• Programs simplify formula use, some apply multiple formulas, commercial software calculates reading levels and gives simplification advice, and specific examples include Readability Calculations, Readability Plus, and they are faster and more accurate for computerized assessments.
• Averaging results from multiple formulas/programs is advisable since readability scores can vary by two grade levels across different formulas/programs.

Tests to Measure Comprehension of Printed Education Materials

• The CLOZE TEST is derived from Gestalt psychology's "closure" concept, removes every fifth word for the reader to fill in the blank, assesses understanding, ranks reading difficulty, and is best for 6th-grade level or higher readers.
• The LISTENING TEST is for lower literacy levels and reads the passage aloud so the listener answers questions orally with scoring as (Correct answers/Total questions) x 100%.
• In the LISTENING TEST, 90%+ equals full comprehension, 75-89% equals needs assistance, and <75% is too difficult.