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
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 opportunities.
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
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?
parents 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 two non-intrusive tools to identify parents for referral to adult basic
education services, family literacy programs, or English language learning
programs. No tests. No embarrassment.
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 a signal to have the Literacy Conversation. More on that
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 7 to 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.
are the ELF questions: (Note: the name
ELF reminds you of the questions)
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.
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 #1 above.
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.
A parents’ limited literacy
translates to limited options and opportunities to maintain a healthy
lifestyle, obtain the full benefit of healthcare, and support their child’s
development. MCH home visitors, other community health workers and many
clinicians can identify parents with limited basic literacy skills (reading)
without testing, embarrassing or alienating them. Once you’ve identified a parent at high risk for low reading
skill, it is time for a reflective conversation. For potentially difficult-to-discuss
topics like this, it is useful to have a Model Reflective Conversation as a
Before you have this conversation, it is essential to become familiar with the
literacy-enhancing services in your area and establish mutually supportive
referral relationships with community partners. Your partner(s) may be a public
library family literacy program, literacy tutors, an adult basic education or
English language learning program. It is not enough to simply have a list of resources.
Visit them. Learn just what you are suggesting parents participate in. Find out
how you can collaborate with program staff to support parents’ participation.
If you have no literacy services in your community, direct your attention to
Reflective Conversation on Literacy
You are going to get a lot of
information about pregnancy and babies from your doctor, your insurance plan,
andfrom me. Most of it will be in
writing. Many people have trouble understanding some of the technical and
medical words and ideas. Have you had any problems reading and understanding
information from your doctor or clinic or other places?
Visitor: OK good. (Leave
the door open for further discussion) I’malways happy to review information with you and help figure out what is
important and what it means for you and your family.
Visitor: (Reassure) Don’t
worry; lots of people do. (Set up the referral) Is it just the medical terms,
or do you think your reading could be
Parent: It’s just the
Visitor: OK good. (Leave the
door open) I’m always happy to review information with you and help figure out
what is importantand what it means
for you and your family. (Give a practical strategy) When the doctor or nurse,
or I use a word you do not understand, you can just repeat the word, like this:
“Ultrasound?” Or “Ultra what?”
My reading could be better.
Visitor: (Reflect. Discover motivations, desired outcomes) How would life be different for you and Baby
if you were a good reader? Wait and listen. (Set up the referral) Would you
like toget some help with your reading?
Parent: No, not now
Visitor: (Discover barriers, fears. Plan a baby step toward participation
in a literacy program.) OK, on a scale of
1-10 where 10 is Can’t-wait-to-learn-to-read-well and 1 is
not-even-thinking-about-it, where are you now? What would it take to
get to (next number)? How will you know you are ready?
Yes, I’d like help with reading.
Visitor: (Offer Information. Keep
the learner in charge of the learning.) There are some good programs in the area that other parents I know
have really liked. Shall I bring you information about them?
You have established referral
relationships with literacy enhancing services in your community. You’ve identified a
parent with reading difficulties and had a reflective
conversation with her about basic literacy. You’ve made the referral. Now the task
is to support the parent’s enrollment and participation.
intensive ongoing support
For the parent and family, becoming a
skilled reader is going to be life-changing and relationship-altering. The process
can be challenging in many personal and practical ways. Enrolling is a huge
step. You can use Dynamic Tension with the parent to anticipate and plan
how to meet the challenges and manage the consequences of becoming
literate. Dynamic Tension, from David Emeralds’ Power of TED*,
The Empowerment Dynamic is a framework for reflective action
planning. In its simplest form, the framework moves through three basic
questions: What do you want? What have you got? What’s next?
1. What do you want? Pick up your earlier reflective
conversation about getting some help with reading where you asked
something like, “How would things be different for you and Baby if you were a
skilled reader?” This gets to the foundational planning question, “what do you want?”
Remember, literacy skills always are used for some practical purpose. Continue
this discussion until the parent has articulated in detail her best possible
desired outcome – the practical purposes of her reading. In challenging times
ahead, you will want to reflect back to her this primary motivation and her
progress toward her vision of her new future as a skilled reader.
have you got? Next, assess current reality. Questions for the parent
include, What will help you make this happen? (social support, especially from
family; encouragement, time to practice, money, child care, transportation). What
might get in the way of you participating in the program? (fear, embarrassment,
resistance of partner). What support will you need? Whom can you ask for that
support? How will you ask? Want to practice?
3. What’s next? Now we get to action – and
anxiety. The essential question is: What baby step can you (the parent) take this week? A baby step
is a small do-able action that has no previous steps and is the parent’s to do.
(If you do it for her, you rob her of learning, experience, success). You may
find there are preliminary steps. Perhaps the parent needs to get glasses
first, or to learn to ride the bus, or find reliable childcare, or all these
things. No matter. Keep her focused on what she wants, and ask which of these
prerequisites she wants to start with. Maybe you’ll decide the first baby step
toward being a skilled reader is to arrange a vision test. Offer assistance (“I
know a good optometrist; would you like his contact information?”) but resist
the temptation to speed the process by doing what is hers to do.
4. Hold the tension. The dynamic tension,
anxiety, arises as soon as she says out loud what she wants. It raises the
possibility of failure. Tension increases as you assess current reality
together because it points to the distance between reality and the goal. Her
natural tendency will be to relieve the tension by letting go of the goal (“I don’t really need to read any
better”). To support the parent in following through on the referral to
literacy-enhancing services, keep her “eyes on the prize” by reflecting back to
her the outcome she wants, her strengths and supports, and her progress. Keep
her taking one baby step after another, building success and confidence along
the way, becoming a problem solver, taking charge of her life. Remind her and
yourself that two steps forward and one step back is still progress; and each
baby step has the potential to be a quantum leap. You will both be amazed by
what she can accomplish.
You’ve referred a
to a literacy enhancing program. Together you and the parent used Dynamic
to put her focus squarely on her vision of her future as a skilled reader. She
has completed preliminary steps and organized the necessary supports. Now the day has come and she is ready
to enroll. This step is the scariest.
New readers talk about driving around the
building for hours; or walking to the door and then back to the car over and
over again before finding the courage to walk in and say out loud, “I need
help”. They say the biggest fear is finding out that they really are stupid.
Before they enroll, they can say the school system failed them. But if they go
to the literacy program and don’t succeed; that would prove that their parents
and teachers and others who said they are stupid were right.
Since many programs rely on volunteers
and are underfunded, the parent might encounter an unskilled teacher, or one
who does not recognize a learning disability. So it is important to become
familiar with programs you refer to (literacy programs for non-readers and up
to about 5 grade level; adult basic education beyond that). You will want to
know about the intake process and how the program manages learning
Literacy expert, Audrey Riffenburgh of Plain Language
offers these ideas to support a person in the enrollment process. First, think
of ways you can ease the anxiety and build confidence:
putting together of group of parents who could attend together and might
evolve to a study group and support group.
§ Whom to call? Just the thought of making an
appointment to enroll is anxiety producing. Offer the contact information along
with a picture of a friendly waving person – ideally the person she will talk
with when she calls, or meet when she enrolls.
§ How to get there? You can use a
Google map and insert photos of landmarks and places a person might get lost if
they cannot read the road signs.
§ What to expect? Make the
experience as predictable as possible by reviewing usual processes, and remind
her that it might not happen exactly as planned.
§ Arrange to meet the parent at the enrollment
if possible. If you go, and you know the person behind the desk, you can
introduce the parent. But your job is to stand by. Do not speak for her.
§ Congratulate her. Reflect back to
her the strengths she demonstrated in completing
§ this huge baby
§ Discuss her
next baby step toward literacy.
does not end here. This is the beginning of the beginning. Closely follow her
progress. Invite her to read aloud to you from the Beginnings Guides or
information from the doctor or community resources. Encourage her to read aloud
to the Baby who will love hearing her voice and not care about mistakes. As
soon as she becomes discouraged or misses a class, check with the director of
the program for help discovering and addressing the problem. Your continued
interest and consistent attention indicates the importance of the challenge and
your belief in her ability to succeed. Your persistent support is a gift that
could transform their lives.
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.
Robbins, S. & Haecker,T. (2003). Screening for low literacy among adult caregivers
of pediatric patients. Family Medicine,
Chew, L. D.,
Bradley, K. A. & Boyko, E. J. (2004). Brief questions to identify patients
with inadequate health literacy. Family
Medicine, 36, 588–594.
(2009). The Power of TED* The Empowerment
Dynamic. Polaris Publishing, Bainbridge Island WA.
Hanley, J. & Soufrant, G. (2008). A single question may be useful for
detecting patients with inadequate
literacy.Journal of General Internal