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Center for Health Literacy Promotion Blog

How to facilitate parents’ participation in literacy-enhancing services

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 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 visitor/family relationship.

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?
Identify 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.

 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 a signal 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 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. 
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 #1 above.  
Interpreting the 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 guide. 

But wait! 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 advocacy.
Model Reflective Conversation on Literacy
Home Visitor:  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?


VisitorOK 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.
OR Parent:Yes

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 better?  
Parent:  It’s just the medical stuff.
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?”
OR Parent: 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?
OR Parent: 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.
Plan 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.  
2.    What 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.  
Support Enrollment
You’ve referred a parent to a literacy enhancing program. Together you and the parent used Dynamic Tension 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 disabilities.
Literacy expert, Audrey Riffenburgh of Plain Language Works, offers these ideas to support a person in the enrollment process. First, think of ways you can ease the anxiety and build confidence:
§ Consider 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 site, 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 step.
§ Discuss her next baby step toward literacy.
Support 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.  
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.

Emerald, David. (2009). The Power of TED* The Empowerment Dynamic. Polaris Publishing, Bainbridge Island WA.

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
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