Addressing health literacy: a description of the intersection of functional literacy and health care.

Abstract: Nearly one in three Americans is functionally illiterate. This is a fact of obvious concern to literacy professionals, those who specialize in promoting children's and adults abilities to use reading, listening, speaking, writing, and critical thinking to participate in society, and a statistic the health care industry also regards as critical (Kefalides, 1999). Clearly, functional illiteracy is one of the most significant problems facing the world's society. Although such citizens might be able to read words, they cannot understand their meanings, synthesize information, or make decisions based on what they read, resulting in negative impacts on the economic, physical health, and social well being of communities. While the connections between literacy levels and health have long been identified as a serious problem, one with implications in both fields (Hohn, 1998), collaboration across the disciplines has been less common (Rudd, Zacharia, and Daube, 1998). In this paper, we explore the illiteracy issue, examine the point at which health and literacy issues intersect, and address the goal of health literacy by offering recommendations for literacy and health practitioners. We present specific examples of the literacy demands necessary for adults to arrange and maintain proper health care for themselves and their children. As part of our discussion, we consider results from the National Survey of Adult Literacy (NALS) in terms of the potential effect that functional illiteracy has on health. In addition, we explore how poverty compounds the problem as we consider the impact that living in poverty has on adults' abilities to make good decisions about health and health care for themselves and for their children. Finally, we offer some suggestions for how governmental, educational private, religious, and other volunteer organizations can collaborate in new ways, in order to address and improve what we call "Health Literacy."

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Nearly one in three Americans is functionally illiterate. This is a fact of obvious concern to literacy professionals, those who specialize in promoting children's and adults abilities to use reading, listening, speaking, writing, and critical thinking to participate in society, and it is also a statistic the health care industry regards as critical (Kefalides, 1999; Rudd et al., 2000; Selden et al., 2000). While the connections between literacy levels and health have long been identified as a serious problem, one with implications in both fields (Hohn, 1998), collaboration across the disciplines has been less common (Rudd, Zacharia, and Daube, 1998; Tolan, 1995). In this paper we explore the illiteracy issue, examine the point at which health and literacy issues intersect, and address the goal of health literacy by offering recommendations for literacy and health practitioners.

In the paragraphs that follow, we present specific examples of the literacy demands necessary for adults to arrange and maintain proper health care for themselves and their children. As part of our discussion, we consider results from the National Survey of Adult Literacy (NALS) in terms of the potential effect that functional illiteracy has on health. In addition, we explore how poverty compounds the problem as we consider the impact that living in poverty has on adults' abilities to make good decisions about health and health care for themselves and for their children. Finally, we offer some suggestions for how governmental, educational, private, religious, and other volunteer organizations can collaborate in new ways in order to address and improve what we call "Health Literacy."

LITERACY DEMANDS AND HEALTH CARE DECISIONS

In 1992, a survey of adult literacy in the United States was conducted by the United States Department of Education's National Center for Education Statistics. The survey included interviews of approximately 13,600 people aged sixteen and above, 1,100 adult inmates, and a thousand other adults who participated in a twelve-state comparison group. Interviewed at their place of residency, respondents were asked to answer questions and complete written exercises that were then evaluated on a five-point scale to determine literacy levels.

According to the National Adult Literacy Survey, literacy is "using printed and written information to function in society, to achieve one's goals, and to develop one's knowledge and potential" (Adult Literacy in America: A First Look at the Results of the National Adult Literacy Survey, 1993, p. 2). This survey allowed researchers to evaluate performance in terms of three literacy types: prose, document, and quantitative literacy (Table 1). Levels One and Two represented the lowest literacy skills, Four and Five reflected mastery of the highest skills, and Three demonstrated functional literacy.

Disturbing news from the survey is that nearly two-thirds of the participants, or approximately ten thousand adults, performed at the lowest levels of literacy--Levels One and Two. These respondents had difficult), responding to problems that required them to "integrate or synthesize information from complex or lengthy texts or to perform quantitative tasks that involved two or more sequential operations and in which the individual had to set up the problem" (Kirch et al, 1993, xv).

Although Level One ranged from adults who could not read at all, to those who could at least write their names or locate the expiration date on a driver's license, participants who scored in this category could not write a letter. They could not read the instructions on a bottle of medicine.

In the Executive Summary of the 1993 Survey Report, the authors point out that, while percentages of adults who perform at the lowest two levels is alarming, it is possible that the low level of literacy does not necessarily have a negative impact on those respondents. According to the data, the majority of adults who demonstrated limited reading skills also reported that they do not get much assistance from others in order to perform everyday literacy tasks.

The report authors wonder if perhaps these adults "are able to meet most of the literacy demands they encounter currently at work, at home, and in their communities" (Kirsch et al, xvii). Then they counter that perspective with a more realistic assessment, one which includes attention to the connections between literacy skills and social and economic variables such as voting, economic status, weeks worked, and earnings reported in the survey: "Literacy can be thought of as a currency in this society. Just as adults with little money have difficulty meeting their basic needs, those with limited literacy skills are likely to find it more challenging to pursue their goals--whether these involve job advancement, consumer decision making, citizenship, or other aspects of their lives" (xix).

Our discussion focuses on those adults who demonstrated the lowest levels of literacy, those who performed at Level One and Level Two. Given the increasing complexity of medical knowledge and the costs of health literacy, inadequate literacy skills may be a barrier to receiving appropriate health care. For example, doctors routinely expect patients to read and understand labels on medicine containers, appointment slips, informed consent documents, and health education materials. Those patients who function at Levels One or Two do not have the literacy skills to perform these tasks.

Inadequate functional health literacy places even a greater barrier to educating patients with chronic diseases. Chronic diseases, such as diabetes and hypertension require that patients receive education in order to achieve control of their behavior and lifestyle; education may help them avoid, or address, adverse health outcomes. For example, patients with diabetes need to understand how to modify their lifestyles (e.g., diabetic diet, monitor their glucose levels at home) and improve their self-management skills. Patient education also plays a major role in facilitating patients' acceptance of their diagnosis and active participation in treatment (Williams et al., 1998). If programs in disease management and patient education are to be successful, health providers who are involved in patient education must consider the possibility that patients may have inadequate literacy.

Several studies have described the difficulties encountered by illiterate patients in understanding health education materials and consent forms that are often written at levels exceeding patients' reading levels (Grundner, 1980; Jaycox, 1989; Lee, 1999; Meade and Byrd, 1989). A study of patient literacy in two urban public hospitals reported in The Journal of the American Medical Association (JAMA), December 1995, caused alarm when it revealed the high number of patients who could not follow basic medical instructions. Many patients were unable to read and understand directions such as, "avoid taking medication on an empty stomach" or to understand when their next appointments were scheduled. Approximately seventy-five percent of those participating in the study could not understand a consent form. This lack of understanding raises ethical questions for doctors concerned about the ability of their patients to effectively participate in their own health care.

Adults with limited literacy encounter many problems using the health care system. They are less likely to use screening procedures, follow medical regimens, keep appointments, or seek help in the course of a disease (Weiss, Hart, and Pust, 1991). Lack of literacy skills also creates barriers to health care by placing functionally illiterate adults outside a societal flow of information that brings people to health care. For example, they cannot access messages from magazine articles, posters in supermarkets, or billboards about the value of vaccinations or flu shots. Moreover, illiterates are more likely to be "fatalistic" about illness and less likely to adopt many of the newer alternatives in treatment of illness (Caldwell, 1979).

Although adults may perceive themselves as able to deal with the information demands of turn-of-the-century society, if they fail to see a problem with their own literacy skills, they might pose a risk to themselves and to their children, extending beyond economic disadvantage itself. Adults who have extreme difficulty interpreting print or numerical information, even if they do not recognize their own limits, are likely to make mistakes that threaten their own health and the health of their children.

THE INTERSECTION OF LITERACY AND HEALTH ISSUES: A SCENARIO

In what ways could low performance on the literacy indicators suggest a problem for the health of the low-scoring adults and their children? Extrapolating from definitions and examples provided in the National Center for Education Statistics report, Adult Literacy in America (Kirsch et al, 1993), we have created the following scenario as a vehicle for examining the intersection of literacy and health issues. Our goal in creating this scenario is to focus even broader concerns about the negative impact of an adult's low literacy on their children's health. Specifically, we will address the literacy requirements that must be met before parents see to it that their children receive the vaccinations required of public school children.

Adults must negotiate several steps to ensure that children receive proper vaccinations before they can attend public schools. First, the parents have to understand, through word of mouth, printed material, or non-print media, that the vaccinations are essential. If parents have extreme difficulty reading texts, they may not understand an announcement that a child brings home from day care about the need for shots; and they may have to rely on friends to explain the requirements to them. Misinformation could easily be passed along at this early stage; thus, it could easily spread and grow. Because vaccinations must occur as a series of shots over time, the parents may also have to rely on someone else to schedule the shots at proper intervals (Kirsch et al, 75-77).

Next, the parents must then arrange for the children to go to an office where the series of vaccinations can be given. Can they read a bus schedule, interpreting it in terms of the location of their home and the health professional's office, times of departure and arrival, and the time of the office appointment? If they have to take a bus plus a taxi, can they calculate the total cost of a two-way trip? Not if their document and quantitative literacy level performances are at Level One (Kirsch et al, 88).

Once they arrive at the health professional's office it is likely that the parents will be able to perform the simple task of signing the name (though some of those surveyed were unable to perform even the simplest of prose or document tasks). It is unlikely, however, that they would be able to write about the reason for the day's visit, even if provided a list of possible and appropriate choices, unless they perform at prose Level Two or above (Kirsch et al, 76). Further, if they are asked how may months have lapsed since the time their children had their last vaccinations, they may have trouble providing an answer if their quantitative literacy performance is at Level One (Kirsch et al, 94).

When adults who are functionally illiterate bring children to a doctor's office, the adults may not be able to understand questions about their children's health histories, thus the information they provide for doctors and nurses may be flawed or incomplete.

During the appointment, the health-care professional may determine that one of the children needs some type of therapeutic agent, such as a prescription or over-the-counter medication. The parents are again faced with a literacy issue. They may be unable to comprehend directions for giving a medication and for monitoring and reporting a child's condition.

Adults who are functionally illiterate may not understand how to get in touch with appropriate health care physicians and other health care professionals when a child is ill or malnourished. They may not be able to correctly administer medications because they cannot read and understand labels on medicine bottles, or to follow the instructions of doctors and other health care professionals. These adults may not be able to make informed choices about the best resources that are available to them and their children; they may have difficulty separating medical information from lore or superstition, and thus fail to provide necessary help to their children. They are most certainly unable to make sense of the complicated package inserts that accompany prescription medicines.

WHEN POVERTY COMPOUNDS THE PROBLEM: SOCIOECONOMIC STATUS AND HEALTH

Medical literature reveals that socioeconomic status, the mix of factors such as income, education, profession, or some combination of the three that shape a person's relative advantage as a participant in society, is a powerful determinant of health (Angell, 1993; Hurowitz, 1993). Illiterates are more likely to live in poverty, to have fewer years of education, to have more health problems, to be older, or to be in prison. Older Americans and minorities, who are the primary users of Medicare and Medicaid, are twice as likely to have impaired literacy than the general population (Kirsch et al. 1993; Williams et al, 1998).

Certainly, more research is needed to examine how thoroughly age, race, gender, and individual socioeconomic position affects individual health (Robert, 1999), but it's clear that the levels of risk in the vacination scenario described above are significant if the parent is elderly, African American, female, poor, or homeless (Ayanian, 1994).

Certainly, marginalized individuals, often populations in the poorest health, may not even be included in many studies involving illiteracy and health care. For example, researchers possit that the risk of homelessness is higher in non-high school graduates, and most homeless live with limited health and medical resources (Wojtusik and Castle White, 1998).

INCOME, LITERACY, AND HEALTH CONCERNS

It appears that people of higher socioeconomic status have adopted healthy lifestyles more rapidly than their counterparts, poorer and less educated people. There is a direct relationship between affluence, literacy, and access to use of health care. A family with financial resources has a higher capacity to buy health-related products and services, such as better nutrition, quality of residence, medical care and items that allow the maintenance of personal and household hygiene.

In 1991, seven percent of Americans with low incomes (below ten thousand dollars annually) described themselves as being in poor health, as compared with less than one-percent of those with incomes over $35,000 annually. The group with the lowest incomes was about four times as likely to be hospitalized as the highest-income group. The disparity was especially striking for certain chronic diseases, such as asthma and diabetes. The poor were eight times more likely to be hospitalized for these illnesses than those with higher incomes, and they had more severe diseases as the time of hospitalization (Angell, 1993).

Illiteracy severly limits employment opportunities and often results in a lack of health services, medical care, and basic healthy living conditions. Guralnick et al. (1993) reported that the health of black Americans was more affected by lower socioeconomic status than by race, and Keil et al. (1993) found that education rather than race was more strongly associated with mortality from coronary disease.

Many studies show that socioeconomic status is one of the most important influences on mortality and morbidity. Pappas et al. (1993) examined changes in mortality rates from 1960 through 1986 according to income and education levels. Despite an overall decline in death rates in the United States since 1960, poor and poorly educated people still have higher death rates than wealthier or more educated people in the same age bracket, and these differences increased between 1960 through 1986. The authors revealed that Americans with a yearly income of less than nine thousand dollars had a death rate three to seven times higher (depending on race and sex) than those with a yearly income of 25,000 dollars or more. Americans who had not graduated from high school had a death rate two to three times higher than those who had graduated from college.

Although the gap in mortality between the privileged and the unprivileged is very large, and has been growing wider, a health care system can only build a healthy society to the degree that other social systems work. Clearly, there is a relationship between health and socioeconomic class and several researchers have suggested there should be a social model of health that views low-income and education as risk factors (Robert, 1999; Sanders-Phillips and Davis, 1998).

Hurowitz (1993) cautions against expecting too much from reform of the health care system without more fundamental social and economic reform. Moreover, he is critical of the tendency to view the effects of socioeconomic problems as purely medical matters. He considers such an approach to be expensive and ineffective. Hurowitz argues that we need to establish a "National Institute of Social Health" to study the social factors influencing health.

The point Hurowitz maintains is that social problems should be resolved mainly through nonmedical means; consequently, the medical care system will be smaller, cheaper, and more narrowly focused than in the current system. Medical care providers would be able to concentrate on providing medical care by responding to acute and chronic disease, focusing on screening, and lessening the discomfort and dysfunction associated with disease. We agree that illiteracy is not a disease that needs to be medicalized.

The need to improve American people's health is more complex than a dichotomy between socially caused and medically caused disease. In order to achieve health literacy, it is not only important to improve the medical system, but it is also necessary to direct efforts to schools, families, and neighborhood settings (Miles & Davis, 1995).

ADDRESSING HEALTH LITERACY

The health care system in the United States requires that patients be able to read. Many patients do not read well enough to adequately function in health care settings, and inadequate literacy skills are an increasing barrier to good health care. The myriad of complex issues inherent in health literacy needs to be addressed by collaboration between health and literacy experts.

A physician's role should not be limited to treating illness; but rather, it should include preventing illness before it occurs. It is not sufficient to list a patient's risk factors; providers should know how to help patients recognize the problems of functional illiteracy in order to change behaviors. Skills such as risk management, risk-behavior change, counseling, and health education should be added to the basic health professional curriculum.

According to a recent editorial in The New York Times (March, 2000) entitled "Tackling the Problems of Health Illiteracy," the American Medical Foundation, a subgroup of the American Medical Association, has begun raising and allocating funds to develop methods and combat the problem. Specifically, the American Medical Association has called for increased funding to educate medical professionals in strategies for detecting illiteracy.

Health care professionals are becoming more sensitive to the prevalence, significance, and management of illiteracy and have begun to implement strategies to assist illiterate patients.

Toward that end, careful analysis of patients is expanding to include methods of detection that are subtle and unobtrusive (Table 2). Clinicians, hospitals, and clinics, for example, might utilize strategies like the following for identifying recipients with low literacy skills:

Often those with low levels of literacy may not recognize that they have a problem, or out of a sense of shame, they may try to hide their problem. In one study reported by Miles and Davis (1995), almost 67 percent of illiterate patients never told their spouses, 53 percent had never told their children, and nineteen percent never disclosed their problems to anyone. Such a culture of silence increases the difficulty of health care professionals who want to recognize and respond to illiterate recipients.

Certainly, patients and health care workers need to communicate in ways that are clear and understandable; moreover, medical care personnel need to be sensitive to the emotional needs of patients with low literacy skills.

In addition to being able to recognize the importance of not embarrassing patients or reinforcing their reading disability, medical professionals are becoming increasingly skilled. Detection and intervention suggestions from the profession (Kefaliedes, 1999; Lee, 1999; Osborne, 1999) are listed in on the previous page.

Simplifying reading materials works. To typify, when low-level literacy patients were provided a one-page educational handout written at a very low readability level encouraging them to "ask your doctor" about pneumonia vaccinations, they were four times more likely to ask than those in the control group (Jacobson et al., 1999).

Such studies show why clinicians should provide patients with clear health instructions, ensure that it is understood, and when possible use the "show me" approach to patient education in which patients are asked to demonstrate or recount how they will take medication or follow other instructions.

Health centers should implement an appropriate set of health education activities and health-promoting interventions. The impact of the interventions in the target population should be assessed at periodic intervals and the results of this evaluation should be used to improve patient care programs (Showstack, 1992).

Much of the conversation has been limited to hospital or clinical settings. We encourage the discourse to widen as well as deepen. For example, Williams, et al. (1998) found that language barriers, particularly for Spanish-speaking patients, may be as important as reading difficulties. This area of concern, while not addressed in this paper, wants further discussion.

In addition, when educating patients of various backgrounds, health care organizations need to pay attention to what makes each ethnic group unique. It is not enough to translate patient education information literally into new languages. It is important that health care organizations be certain that the materials their patients receive have contents that make sense to them. Health educators should pay attention to criteria such as linguistic accuracy, cultural relevance, and cultural sensitivity.

Rather than blame the victim, many concerned with this issue advocate patient empowerment (Vernarec, 1999). According to David Baker, a researcher in the field, "Millions of Americans cannot achieve health literacy until we can find better ways of communication with them. Rewriting brochures won't get us where we want to go. What we're talking about is a new paradigm, where we determine patients' learning capabilities" (Marwick, 1997).

To improve health outcomes within the community and in conjunction with fostering strategies for working with individual patients, it is also recommended that health care professionals focus on a wider social perspective. A population perspective necessitates knowledge of population needs, of a cultural perspective of illness, and of the impact of social and community influences on individuals.

Studies funded by the Robert Wood Johnson Foundation, managed care plans, and other interested parties have questioned the relationship between inadequate health literacy and illness across a variety of settings; have developed methods for assessing functional health literacy, and have explored a variety of interventions (Williams et al., 1998).

Community-wide empowerment projects are proving to have impressive results. After one year, the Healthwise project, funded by the Robert Wood Johnson Foundation and community businesses, distributed 132,000 health handbooks, led eight hundred workshops, set up a nurse-staffed phone center, and established fifty-two information stations with reference books and other support materials (Vernarec, 1999).

Efforts and resources should continue to be directed towards schools, families, and neighborhood settings in which the opportunity for literacy is lost (Miles & Davis, 1995). Resources might need to be allocated to build and support schools where teachers can teach and communities where children can learn, and thus improve the health and quality of life for adults and their children.

The 1993 Education Reform Act targeted adult education and state funding for family literacy has increased as a result (Gormley, 1997). Resources to contact include the National Institute for Literacy in Washington DC, System for Adult Basic Education Support in Lawrence, Massachusetts, and World Education in Boston.

Schools cannot do the job alone. Nine in ten Fortune 1000 CEOs recognize illiteracy as a problem in the workplace, and many industries have worker literacy programs in place (Reese, 1996). Partnerships between health care providers and literacy professionals are having some significant successes. The primary responsibility for achieving higher standards for health literacy must be shared and increased collaboration must be fostered.

CONCLUSION

Adult illiteracy is a serious problem that undermines both the individual's and the community's health and quality of life. The most common causes of illiteracy include poverty, low parental educational attainment, and home environments in which parents are unable to instill basic literacy skills, especially reading, in their children.

Since the National Adult Literacy Survey (NALS) was conducted, the definition of literacy has shifted from a basic description of reading and writing skills to a concern for whether a person's educational level is adequate to function in a modern society and a more comprehensive understanding of functional literacy. Improved literacy provides individuals with the fundamental skills they need to improve their health and their lifestyles.

Do health educators have reasons to work with literacy professionals, if one goal of health educators is to improve the quality of health care provided to the children of adults who have not achieved literacy? Should literacy experts consider the basic human needs of safety, shelter, and food when planning to work with adult illiterates, if one of their goals is to improve the quality of life among adults who cannot read, write, or use quantitative information? The answer to both questions should be an enthusiastic "Yes!"

Table 1. NALS Rubric for Assessing Adult Literacy.

Literacy Level   Prose Literacy              Document Literacy

      1          Requires the reader to      Requires the reader to
                 locate a single piece of    locate a piece of
                 information that is         information based on a
                 identical to or             literal match, or enter
                 synonymous with the         information onto a
                 information given in the    document, when little, if
                 question, when the text     any distracting
                 is short; or when           information is present,
                 plausible but incorrect     or when the information
                 information is either not   requested is personal.
                 present, or is present
                 but located away from the
                 correct information.

      2          Requires the reader to      Requires the reader to
                 locate a single piece of    match a single piece of
                 information in the text,    information, cycle
                 compare and contrast        through information in a
                 easily identifiable         document, integrate
                 information based on a      information from various
                 criterion provided in the   parts of a document, or
                 question, or integrate      generate written
                 two or more pieces          information by entering
                 of information, when        requested information in
                 distractors are present;    the proper place, when
                 or when low-level           several distractors are
                 inferences are required.    present, or when the
                                             match requires low-level
                                             inferences.

      3          Requires the reader to      Requires the reader to
                 match literal or            cycle through the
                 synonymous information in   information, integrate
                 the text with that          multiple pieces of
                 requested by the task,      information from one or
                 integrate multiple pieces   more documents, or
                 of information, or          generate new information
                 generate a response based   by entering requested
                 on information that can     information in the proper
                 be easily identified in     place, when complex
                 the text, when the text     tables or graphs contain
                 is dense or lengthy or      irrelevant information;
                 contains no headings or     or when the match
                 other organizational        requires inferences.
                 aids; when distracting
                 information is present,
                 but is not located near
                 the correct information;
                 or when low-level
                 inferences are needed.

      4          Requires the reader to      Requires the reader to
                 search text and match on    match on multiple
                 multiple features,          features, cycle through
                 integrate or synthesize     the information,
                 multiple pieces of          integrate multiple pieces
                 information, or generate    of information from one
                 new information by          or more documents, or
                 combining the information   generate new information
                 provided with common        by entering requested
                 knowledge, when the         information in the proper
                 passages are complex or     place, when conditional
                 lengthy; when conditional   information is present
                 information is requested    in the document; when a
                 by the task; or when more   greater degree of
                 complex inferences are      inferencing is needed; or
                 needed.                     when numerous (but
                                             unspecified) responses
                                             are needed.

      5          Requires the reader to      Requires the reader to
                 search text and match on    match on multiple
                 multiple features,          features, cycle through
                 compare and contrast        the information, or
                 complex information, or     integrate multiple pieces
                 generate new information    of information from one
                 by combining the            or more documents, or
                 information provided        generate new information
                 with common knowledge,      by entering requested
                 when the passages are       information in the proper
                 dense and contain a         place, when information
                 number of plausible         displays are complex and
                 distractors; when           contain multiple
                 high-level, text-based      distractors; when
                 inferences are needed; or   high-level, text-based
                 when specialized            inferences are needed;
                 background knowledge is     or when specialized
                 required.                   knowledge is required.

Literacy Level   Quantitative Literacy

      1          Requires the reader to
                 perform a single,
                 relatively simple
                 arithmetic operation,
                 such as addition, when the
                 numbers used are provided
                 and the arithmetic
                 operation to be performed
                 is specified.

      2          Requires the reader to
                 locate numbers by
                 matching the needed
                 information with that
                 given, infer the
                 necessary arithmetic
                 operation, or perform a
                 single arithmetic
                 operation, when the
                 numbers and the operation
                 to be performed are
                 stated in the task; when
                 the quantities are easily
                 located in the text or
                 document; or when the
                 operation is easily
                 determined from the
                 format of the material.

      3          Requires the reader to
                 locate numbers by
                 matching the needed
                 information with that
                 given, infer the
                 necessary arithmetic
                 operation, or perform
                 arithmetic operations on
                 two or more numbers or
                 solve a problem, when the
                 numbers must be located
                 in the text or document;
                 or when the operation(s)
                 needed can be determined
                 from the
                 arithmetic-relation terms
                 used in the question.

      4          Requires the reader to
                 locate numbers by
                 matching the needed
                 information with that
                 given, infer the
                 necessary arithmetic
                 operation, perform two
                 or more sequential
                 operations or a single
                 arithmetic operation,
                 when the quantities are
                 found in different types
                 of displays, or when the
                 operations must be
                 inferred from semantic
                 information given or
                 drawn from prior
                 knowledge.

      5          Requires the reader to
                 locate numbers by
                 matching the needed
                 information with that
                 given, infer the
                 necessary arithmetic
                 operation, or perform
                 multiple arithmetic
                 operations sequentially,
                 when the features of the
                 problem must be
                 diembedded from text; or
                 when background knowledge
                 is required to determine
                 the quantities or
                 operations needed.
Table 2. Ten Signs of Functional Illiteracy in Adults.

1. Do they ask you to fill out forms for them, or make a lot of
mistakes when they fill them out for themselves?

2. Do they bring a friend to help with forms?

3. Do they take forms home to fill out?

4. Do they make excuses for not reading brochures or written
explanations of services: "I forgot my glasses." "I have
a headache." Or "I don't have time."

5. Do they repeatedly ask you to explain what they have just read?

6. Do their eyes fail to move right while "reading"?

7. Do the fail to respond to mailed notices, bills, etc.?

8. Do they ask you to call rather than mail the information to them?

9. Do they continuously forget appointments?

10. Do they turn down opportunities that require reading and/or
writing?
Table 3. Suggestions for Detection and Intervention.

* Never assume that your patients know how to read.

* Do not directly question patients to find out. Instead, ask them
how they learn best.

* Notice when patients ask others to read for them or make excuses to
avoid reading.

* Hand the patient written material upside down.

* Utilize pictographs to explain medical instructions.

* Restate instructions and use simple language.

* Ask patient to repeat instructions.

* Demonstrate tasks whenever possible.

* Simplify the reading materials.

* Screen patients with multiple medical problems who are at high risk.

* Consider using a screening test such as the Rapid Estimate of Adult
Literacy in Medicine (REALM) or The Test
of Functional Health Literacy, in Adults (TOFHLA).

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David Foulk, Ph.D., is Department Chair, Pamela Carroll, Ph.D. and Susan Nelson Wood, Ph.D. are faculty in the Department of Curriculum and Instruction at the Florida State University. Address all correspondence to Dr. Nelson Wood at the Department of Curriculum and Instruction; The Florida State University; Tallahassee, FL 32306-4490; Email: [e-mail].