Any way they are defined, any way they are measured, health
and literacy are inextricably linked. Parents’ literacy is a
determinant of child health. Low literacy is a barrier to delivery
of healthcare services and home visitation services. Achieving
family goals and program goals for health, school readiness,
healthy child development, and self-sufficiency
depends on parents’ ability to use information and
resources. For these reasons, literacy should be a priority
for all MCH home visiting programs.
I have argued that reading is neither necessary nor sufficient
to function in modern society, particularly in healthcare. Everyday,
people who read poorly or not at all manage to access healthcare,
keep a job, and raise competent children. But the fact remains,
those folks are extraordinary. They have developed other skills to
compensate. For most, inability to read severely restricts options and
Literacy has long been framed as a reflection of cognitive ability so
that being “low literate” bears a powerful stigma. This makes reading
difficulty one of those hard-to-discuss topics that are easily skipped for
fear of jeopardizing the essential and sometimes fragile visitor/family
Some of the discomfort comes from our own, perhaps unconscious,
beliefs about literacy. In many communities, everyone “just knows”
that low literacy is on the list of Things Too Bad Too Talk About.
Home visitors tell me they do not want to embarrass parents, or
insult them, or make them uncomfortable when everyone is comfortable.
Breakthrough happens out of discomfort. And you, Non-judgmental Visitors,
have the capacity to hold a safe space for “your” parents’ to work through
discomfort and move toward higher functioning.
If not you, then who?
The first task is to identify parents who are at
high risk for low literacy.
The point of identification is to refer them to community-based
literacy enhancing services and support their participation.
All this can be accomplished in a positive,self-esteem building way.
And that may be the greatest gift you can offer a family.
To start, I offer a two non-intrusive tools to identify parents
for referral to adult basic education services, family literacy
programs, or English language learning programs. No tests.
1. Observe how many adult and/or children’s books are in the home.
Or ask, How many books do you have? (They can be library books.)
Research shows that parents who have at least 10 adult or children’s books
get satisfactory scores on reading tests – they probably read well enough.
If you see no reading materials, that’s asignal to have the Literacy
Conversation. More on that later
2. Use the ELF Literacy Screen. The ELF uses three questions to
produce a proxy REALM score. REALM – Rapid Estimate of Adult Literacy
in Medicine – is the most commonly used measure of reading ability in
a healthcare setting. It is a word recognition test using healthcare-related
terms (e.g. exercise, menopause, jaundice). The ELF was designed by
a primary care physician to identify poor readers without giving them the
test, which patients have reported is embarrassing and alienating.
The ELF was validated with low-income parents of children to age 6 in
primary care. Researchers gave the REALM test to the parents and then
asked them a list of questions. Their responses to the following three
questions correlated with scores indicating a reading level equivalent
of < 6 grade or > 7 grade. (The average American reads at a 7to 8
grade level). You can identify most poor readers by their response to
three questions. You might already have the info, so you won’t even
need to ask.
Here are the ELF questions:
(Note: the name ELF reminds you of the questions)
· How many years of Education did you complete?
The critical answer is > 12 years; high school graduation predicts a
reading level equivalent to 7 to 9 grade. No-diploma predicts lower reading
ability. When a parent has not graduated from high school, this really is as
far as you need to go to know that the Literacy Conversation is in order.
A perhaps easier way to ask the question is: Were you able to finish
high school? In most programs, the easiest way to get the answer is to look
at the record.
· Are you currently Living with your child’s other parent?
Do not read into this question. It is not to indicate that living with the
father of the baby makes a woman smarter. It probably indicates
some level of social support and the wherewithal to maintain a relationship.
This info likely is in the record, too.
· Do you ever read books for Fun? This relates to observing
the number of books in the home as described in #1above.
Interpretingthe answers to the ELF Questions A parent who has
graduated from high school (or has a GED) and says Yes to at least
one of the other questions probably has adequate reading skills.
Others are at high risk for low literacy and may benefit by referral,
support to participate in a literacy program, and direct assistance
to make meaning from information and apply it in context.
Next: Making the referral to literacy enhancing services.
Baker, D.W., Parker, R.M., Williams, M.V., Clark, W.S. & Nurss, J. (1997).
The relationship of patient reading ability to self-reported health and use of health services.
American Journal of Public Health, 87 (6), 1027-1030.
Bennett, I.M., Robbins, S. & Haecker,T. (2003). Screening for low literacy among adult
caregivers of pediatric patients. Family Medicine, 35, 585-590.
Chew, L. D., Bradley, K. A. & Boyko, E. J. (2004). Brief questions to identify
patients with inadequate health literacy. Family Medicine, 36, 588–594.
Garcia, C.H., Hanley, J. & Soufrant, G. (2008). A single question may be useful for
detecting patients with inadequate literacy. Journal of General Internal Medicine, 23(9), 15