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You are reading: What is health literacy?
Institute of Medicine (US) Committee on Health Literacy; Nielsen-Bohlman L, Panzer AM, Kindig DA, editors. Health Literacy: A Prescription to End Confusion. Washington (DC): National Academies Press (US); 2004.
Institute of Medicine (US) Committee on Health Literacy; Nielsen-Bohlman L, Panzer AM, Kindig DA, editors.
A 29-year-old African-American woman with three days of abdominal pain và fever was brought khổng lồ a Baltimore emergency department by her family. After a brief evaluation she was told that she would need an exploratory laparotomy. She subsequently became agitated & demanded to lớn have sầu her family take her home page. When approached by staff, she yelled “I came here in pain & all you want is khổng lồ vị is an exploratory on me! You will not make me a guinea pig!” She refused to lớn consent to lớn any procedures và later died of appendicitis.
DEFINITION OF HEALTH LITERACY
Health literacy is of concern to lớn everyone involved in health promotion and protection, disease prevention và early screening, health care và maintenance, và policy making. Health literacy skills are needed for dialogue and discussion, reading health information, interpreting charts, making decisions about participating in research studies, using medical tools for personal or familial health care—such as a peak flow meter or thermometer—calculating timing or dosage of medicine, or voting on health or environmental issues. This report makes use of the operational definition of health literacy developed for the National Library of Medicine và used by Healthy People 2010:
The degree khổng lồ which individuals have sầu the capathành phố lớn obtain, process, and understvà basic health information và services needed to make appropriate health decisions (Ratzan and Parker, 2000).
The capađô thị of the individual is a substantial contributor to lớn health literacy. The term “capacity” refers khổng lồ both the innate potential of the individual, as well as his or her skills. An individual”s health literacy capađô thị is mediated by education, and its adequacy is affected by culture, language, & the characteristics of health-related settings. In this report, the committee has captured the range of environments và situations related khổng lồ health in the term “health context”. The health context includes the truyền thông media, the marketplace, & government agencies, as well as those individuals and materials a person interacts with regarding health—all must be able khổng lồ provide basic health information in an appropriate manner (Rudd, 2003). This health context is of equal importance to individuals” health literacy skills, as the impact of health literacy arises from the interaction of the individual and the health context (Rudd, 2003; Rudd et al., 2003). Health literacy, then, is a shared function of cultural, social, & individual factors. Both the causes and the remedies for limited health literacy rest with our cultural & social framework, the health & education systems that serve sầu it, and the interactions between these factors.
A Conceptual Framework for Health Literacy
Figures 2-1 & 2-2 provide visual frameworks for considering health literacy. Figure 2-1 places literacy as the foundation of health literacy & health literacy as the active mediator between individuals and health contexts. Individuals bring specific sets of factors to the health context, including cognitive sầu abilities, social skills, emotional state, & physical conditions such as visual & auditory acuity. Literacy provides the skills that enable individuals khổng lồ understand & communicate health information and concerns. Literacy is defined as a phối of reading, writing, basic mathematics, speech, và speech comprehension skills (Kirsch, 2001a). Health literacy is the bridge between the literacy (và other) skills & abilities of the individual & the health context. This interaction is explored in Chapter 3, where associations between health literacy & health-related outcomes are discussed in detail.
Figure 2-2 illustrates the three key sectors that should assume responsibility for health literacy, and within which health literacy skills can be built. The sectors that constitute the contexts of health literacy are culture and society, the health system, and the education system. These sectors also provide intervention points that are both challenges & opportunities for improving health literacy.
Figure 2-2 illustrates the interaction of individuals with education systems, health systems, and societal factors as they relate to health literacy. It is not a causal Mã Sản Phẩm. It is likely that the determinants of health literacy are as varied và complex as those of the most refractory problems now facing the health fields. Although causal relationships between limited health literacy & health outcomes are not yet established, cumulative and consistent findings suggest such a causal connection. Retìm kiếm is needed to lớn establish the nature of the causal relationships between và aao ước these factors. Mapping this website of causation should be a goal of research, but it is important lớn note that current knowledge can serve sầu as the basis for changing practice và policy. Below, we introduce the role each of the sectors plays in supporting or impairing health literacy. The opportunities for & obstacles to lớn health literacy in these three sectors will be discussed in detail in Chapters 4, 5, & 6.
Culture và Society
The term “culture” in this report primarily refers khổng lồ the shared ideas, meanings, and values acquired by individuals as members of society. Cultural, social, & family influences are of critical importance in shaping attitudes & beliefs. In this way, they influence how people interact with the health system và help determine the adequacy of health literacy skills in different settings. People know humanity, khuyễn mãi giảm giá with the world they live sầu in, và underst& their place in the universe through cultural processes. Conditions over which the individual has little or no control but which affect the ability khổng lồ participate fully in a health-literate society comprise social determinants of health. Included are native language, socioeconomic status, gender, race, and ethniđô thị, along with influences of mass truyền thông as represented by news publishing, advertising, sale, và the plethora of health information sources available through electronic sources. Culture is crucial for understanding, thinking, and responding khổng lồ human experiences & world events. American culture is formed from historical, racial-ethnic, social, political, psychological, educational, & economic forces that are woven into the context of American lifestyles. Because they are pathways khổng lồ understanding American life, cultural contexts should be harnessed in the quest for a health-literate America.
The Education System
The education system in the United States consists of the K-12 system, adult education programs, và higher education. K-12 education is charged with the development of literacy và numeracy skills in English, which cumulatively khung the foundation for more complex skills involving comprehension và application in the later grades. Adult education programs provide opportunities for individuals who drop out of K-12 education for academic or social reasons, for those who completed high school but did not acquire strong skills, for elders who did not have sầu full schooling opportunities, & for adult immigrants who may never have sầu had access lớn education and/or wish lớn learn lớn speak, read, and write English. Individuals with college-level education or higher frequently have sầu adequate literacy skills, & generally are not discussed in this report. Formative sầu and continuing education for health professionals is also considered within the context of education.
The Health System
Within the many components of health-care systems, health-related messages and action plans are crafted, rights và responsibilities are shaped, retìm kiếm initiatives are begun, health-promoting recommendations are developed & supported, access is monitored, & regulations are enforced. In this report, we use the term health system lớn refer lớn all people performing these activities, including those working in hospitals, clinics, physician”s offices, home health care, public health agencies, accreditation groups, regulatory agencies, & insurers. Published nhận xét of the literature (for example, see Kerka, 2000; Rudd et al., 2000) và the committees retìm kiếm inlớn the literature from a range of related fields, including health communication & social sale, provide consistent evidence supporting the notion that health literacy affects the interaction of individuals with health contexts và the health-care system, & may further affect health status and outcomes.
Finding 2-1 Literature from a variety of disciplines is consistent in finding that there is strong support for the committee”s conclusion that health literacy as defined in this report is based on the interaction of individuals” skills with health contexts, the health-care system, the education system, và broad social và cultural factors at trang chủ, at work, và in the community. The committee concurs that responsibility for health literacy improvement must be shared by these various sectors. The committee notes that the health system does carry significant but not sole opportunity and responsibility khổng lồ improve sầu health literacy.
Finding 2-2 The link between education and health outcomes are strongly established. The committee concludes that health literacy may be one pathway explaining the well-established link between education và health, & warrants further exploration.
The Scope of Health Literacy
If people who promote health care, create policy, & develop health materials have sầu a clear understanding of the problem of health literacy, procedures, policies, & programs can be developed khổng lồ meet the health literacy needs of the average American adult. A clear understanding of health literacy can guide the health system of public health practitioners, care providers, insurers, & community agencies toward adopting definitions & policies that resolve sầu incompatibilities between the needs of individuals và the demands of health systems. The committee believes that both a commonly accepted definition & a conceptual framework will contribute khổng lồ the clear understanding of health literacy. In choosing the definition & developing the framework in this report the committee examined the existing definitions and concepts of health literacy. The committee believes the definition và framework in this report incorporate aspects essential to lớn the understanding of health literacy, & allow for a flexibility of response within the framework of a widely accepted definition.
Health literacy is a newly emerging concept and field of inquiry, so it is not surprising that the scope of health literacy varies according lớn how it is defined. For example, in 1999, the Ad Hoc Committee on Health Literacy of the American Medical Association defined health literacy as the “constellation of skills, including the ability lớn persize basic reading và numerical tasks required khổng lồ function in the health care environment,” and included everyday health functions such as the “ability khổng lồ read and comprehkết thúc prescription bottles, appointment slips, & other essential health-related materials” (American Medical Association, 1999). This definition captures important components of health care, but confines the scope of health literacy lớn the health-care sector. This committee extends the concept of health literacy beyond health-care settings khổng lồ include the variety of contexts (such as in the community và at work) in which individuals make health-related decisions.
Another concept of health literacy is found in the definition used by the Joint Committee on National Health Education Standards: “the capacity of individuals to obtain, interpret and underst& basic health information & services và the competence lớn use such information & services in ways which enhance health” (Joint Committee on National Health Education Standards, 1995). This definition does move beyond the health-care setting; however, this & similar definitions (e.g., Kickbusch, 1997) maintain a focus on the capacity of individuals and emphasize the characteristics, knowledge, & skills of individuals without attention to lớn the complexity of various health contexts, the tasks involved, or the materials in use.
The committee chose to adopt the definition used in Healthy People 2010 for purposes of measurement và clarity in this report. As previously noted, Healthy People 2010, the document that reports the federal government”s national health objectives, defines health literacy as “the degree to lớn which individuals have sầu the capađô thị to obtain, process, & understvà basic health information and services needed lớn make appropriate health decisions” (HHS, 2000; Ratzan và Parker, 2000). This definition is useful because it encompasses the variety of contexts within which individuals may confront & interact with health issues. As with a number of the other definitions discussed above sầu, however, it focuses attention on and appears khổng lồ limit the problem of health literacy khổng lồ the capathành phố & competence of the individual. This limitation is acknowledged & addressed in the action plan for the Healthy People 2010 health literacy objective sầu, which expands the definition to include system-level contributions (Rudd, 2003). Recognizing the limitations of this definition, the committee acknowledges the need for future development of definitions và measures that address the critical role that society, the health system, and the education system play in creating a truly health-literate America.
DEFINITION OF LITERACY
Educators vị not associate literacy with reading alone, but often consider literacy to lớn represent a constellation of skills including reading, writing, basic mathematical calculations, and speech & speech comprehension skills (Kirsch, 2001a). Speech and speech comprehension are collectively termed oral literacy, while reading và writing are referred lớn as print literacy. For our discussion in this report, we further differentiate among muốn the following terms: basic print literacy, literacy for different types of text, và functional literacy. Basic print literacy ability means the ability lớn read, write, and understvà written language that is familiar and for which one has the requisite amount of background knowledge. Reading or text literacy is related lớn characteristics of the text being read such as complexity and format. Functional literacy is the use of literacy in order to lớn perkhung a particular task. We note that health literacy has been variously defined, but as currently used & measured, often consists of reading or text literacy (see below for further discussion). Figure 2-3 below illustrates the relationships between the different contributors khổng lồ literacy.
As illustrated above in Figure 2-3, a consideration of health literacy must include component parts directly related to the broad concept of literacy. Literacy, as noted earlier, is context specific. For example, literacy could be placed within the multiple health contexts noted earlier. In this case, the construct includes cultural and conceptual knowledge that could include an understanding of health and illness & a conceptualization of risks & benefits. Listening and speaking skills are essential for public health communication, the commercial sector”s advertising goals, & for practitioner–patient interactions, such as for the presentation of symptoms critically needed for diagnosis. Writing and reading skills, often called print literacy, are needed for tasks related lớn the use of the printed word, whether the words are found on labels in the market, in health education brochures, on medicine bottles or in informed consent documents. Numeracy skills are needed to calculate nutrition labels, calibrate temperature, và compare benefit packages, và for determining the proper dosage & timing of medicines. The committee recognizes that these skills are essential components of health literacy. However, most literature focused on health literacy issues has focused predominantly on assessments of materials & on measures of people”s skills based on their ability to lớn read a sample of these materials. Thus, print literacy has dominated the discussion in health literacy so far. At the same time, the focus on print literacy has yielded profound insights into lớn difficulties and barriers linking literacy skills khổng lồ health outcomes.
Finding 2-3 Health literacy, as defined in this report, includes a variety of skills beyond reading và writing, including numeracy, listening, & speaking, and relies on cultural and conceptual knowledge.
Basic Print Literacy
As mentioned earlier, basic print literacy ability means the ability khổng lồ read, write, & underst& written language that is familiar and for which one has the requisite amount of background knowledge. It includes the ability khổng lồ decode letters và sound out words, but also includes the ability to understvà the meaning of the printed text. Some people with limited skills may know how lớn decode letters inlớn sounds và pronounce words but may not be able to lớn underst& the meaning of a sentence formed by these words. However, as many new readers build on these skills, they learn how khổng lồ read words in sentence sequence và accumulate levels of fluency for reading & writing. Fluency in reading includes accuracy, rate, và appropriate phrasing and intonation. Fluent reading “sounds” natural rather than halting & effortful. Basic print literacy is what is referred to lớn when someone inquires, “can he read?” People who are termed “illiterate” have sầu few, if any, of the skills needed for basic print literacy. The terms “low literate” or “limited” reading skills refer to difficulty with reading and comprehending materials written beyond very simple levels.
Literacy for Different Types of Text
Possessing the skills needed for basic literacy does not guarantee that one can read and comprehend all types of written text. Readers must know and understvà the individual words và terms used in the text & be familiar with the concepts addressed in the text. They must understvà how khổng lồ “read” the structure of the text. For example, a prescription label has a chất lượng structure & the reader must be able to lớn use that structure khổng lồ understand the directions that follow. The reader may be helped or hindered by various text features such as font kích cỡ, layout & design, syntax, or use of graphs. Not all texts are equally readable và comprehensible khổng lồ every person, regardless of that person”s reading ability. The same literate person who can read the daily newspaper, the Bible, novels, or a manual at work may not be able to figure out instructions for connecting a DVD player khổng lồ a television, directions for taking medicine, a blueprint for a new skyscraper, or the bias in an editorial. Thus, the readability of different texts depends on the skills & background knowledge of individual readers, factors in the text, and the purpose for which readers use the materials.
All Literacy is Functional
Texts serve sầu specific functions, & readers come to lớn them in order khổng lồ accomplish specific tasks. At times, the task at hand may be clear; for example, a person is most likely khổng lồ read a bus schedule in order lớn determine when the bus is arriving at a certain place. In other cases, the task may be less clear; a person is most likely khổng lồ read a novel for pleasure. In both examples, however, the person is applying literacy skills lớn persize a function.
The content và structure of a bus schedule is meant khổng lồ be a reflection of the function it serves to lớn help a traveler plan an excursion. A bus schedule generally lists the routes & stops of different buses—often identified with numbers—for people who need lớn plan their transportation & arrive at a particular destination at a specific time. More complicated schedules include variations based on days of the week or holiday exceptions. Similarly, the nội dung và structure of a label on a pediatric over-the-counter medicine is designed khổng lồ provide the parent with information about the medicine và a mechanism for calculating the appropriate dose based on the child”s age & weight. This information is often present in a table format that requires special reading skills that many people vì not have sầu.
An individual”s ability to lớn apply his or her literacy skills changes with the challenges of the task (Kirsch, 2001b; Kirsch et al., 1993). The example below, the text of an actual letter sent by a doctor to lớn a patient, captures a very complicated message. Although the patient in this case holds a graduate degree, his anxiety was greatly increased as a result of a confusing message. He asked, “How can I have sầu a recurrence of thyroid cancer if my thyroid was removed?”
Dear Mr. Smith,
The May thyroid tests showed TSH 2.794 μU/ml, which, though “normal,” is too high for someone who has had prior thyroid carcinoma. Keeping TSH between 0.1 – 0.3 μU/ml minimizes recurrence of thyroid cancer. Free T4 1.60 mg% is a high-normal cấp độ.
I suggest you increase L-thyroxine from 150 mcg 7 days a week lớn 150 mcg 5 days a week and 225 mcg (111/22 tablets) Wednesdays và Sundays weekly. Have a repeat TSH, miễn phí T4 và total T3 in 8 weeks. I should also on that occasion like you lớn have sầu a serum plasma metanephrine màn chơi.
Two weeks after having those tests, please see me for a consultative sầu office visit.
Sincerely yours, John Doe, M.D. Endocrinology
Health-related activities take place in a wide variety of settings (trang chủ, work, community health-care institutions) & can involve sầu a wide range of activities related khổng lồ family, community, economics, leisure, and safety issues. The parent taking a child”s temperature, the worker reading about proper procedures for handling materials, the shopper calculating the difference in salternative text nội dung on the labels of two brands of canned vegetables, the patient reading about dental options, & the elder filling out an application for Medicare are all engaged in health-related tasks, in different environments, for different purposes, & with different types of materials. All are applying literacy skills to printed health information.
This report uses the term “health contexts” khổng lồ reflect the many situations and activities relating lớn health. Health contexts are unusual, compared khổng lồ other contexts, because of an ever-present or underlying găng tay or fear factor. Various exposures, products, or actions might enhance health, safeguard health, harm health, or lead khổng lồ very dire consequences. In addition, health-care settings can involve chất lượng conditions such as the physical or mental impairment experienced by a patient due to illness, găng tay, or fear (Alexander, 1990; Dumas, 1966). Health-care settings also involve sầu specialized vocabulary, use of jargon, legal forms, complex procedures and processes, as well as differences in power and access lớn information.
Literacy Skill Demands of Health Contexts
A complex array of health literacy skills are needed for functioning in a variety of health contexts. These skills include reading, writing, mathematics, speaking, listening, using công nghệ, networking, và rhetorical skills associated with requests, advocacy, và complaints. Table 2-1 presents some brief (& incomplete) examples lớn provide a sense of the complexity of skills needed for health.
While many of the examples presented in Table 2-1 emphaform size the skills of individuals, the skills of those communicating also contribute to lớn health literacy. We must consider a health-care provider”s ability khổng lồ use common words and to lớn perceive sầu whether a patient is understanding a discussion or not. A media developer needs the skills to lớn shape a message that consumers can underst&. Manufacturers need skills khổng lồ kiến thiết clear sản phẩm labels. Educators need skills to lớn engage students in health-related issues & lớn incorporate health messages into lớn science, language, và math curricular materials. The example below represents the màn chơi of confusion created by a laông xã of clear information, even for the most educated consumer.
A highly publicized, large-scale study of combination estrogen-progestin hormone therapy by the Women”s Health Initiative sầu came khổng lồ a sudden kết thúc in the summer of 2002 when researchers noticed higher levels of heart disease, blood clots & breast cancer in the group taking hormones.
According to Wyeth spokeswoman Natalie DeVane, 15 million American women were taking some size of hormone treatment before the study was stopped. This past June, she said, the number was 9.2 million.
Rep. Rosa L. DeLauro (D-Conn.) led the effort lớn mandate an FDA education effort on hooc môn therapies. “I”m pretty well-informed about these things, và I didn”t know what khổng lồ bởi vì,” she said. “In the absence of clear information, it can get pretty scary for women.” (Kaufman, 2003)
MEASURES USED IN HEALTH LITERACY RESEARCH
Measures of literacy are needed to allow us to assess people”s literacy competence và khổng lồ suggest promising intervention points & strategies. However, we must recognize that assessment of literacy ability (as for any assessment) depends on how literacy is defined and how assessment results are to lớn be used. Literacy assessment has evolved over the years & takes several different forms, resulting in the necessity to lớn interpret & use the results accordingly.
Assessments of adult literacy conducted since the late 1980s have sầu focused on functional literacy & numeracy as outlined by the National Literacy Act of 1991.1 This act defines literacy as “the ability lớn read, write, và speak in English, and compute & solve sầu problems at levels of proficiency necessary lớn function on the job và in society, to lớn achieve one”s goals, và develop one”s knowledge and potential.” This definition was applied to lớn the development of the national assessments of adult literacy in the United States và other industrialized nations. The surveys measured three of the five accepted components of literacy: reading, writing, & mathematical calculations (or numeracy). Oral language skills, including speaking & listening, were not assessed for the national studies, in part because of time constraints và a possible burden on participants (Kirsch, 2001a). The Young Adult Literacy Survey (performed in 1985) (Kirsch and Jungeblut, 1986), the Department of Labor Survey (1990) (Kirsch and Jungeblut, 1992), the National Adult Literacy Survey (NALS) (1992) (Campbell et al., 1992), và the International Adult Literacy Survey (IALS) (the initial study was performed in 1994–1998) (Kirsch, 2001a) all focus on the ability to lớn use print materials to lớn accomplish a task. These task-oriented assessments differ in complexity from basic literacy assessments that focus on the ability to lớn recognize or pronounce words, or lớn read và comprehover text written specifically for chạy thử purposes.
Materials for these surveys were drawn from six contexts in order lớn represent literacy tasks from everyday life: trang chủ và family, health & safety, community & citizenship, consumer economics, work, and leisure và recreation. Materials included both continuous & noncontinuous texts. Continuous texts or prose, which is the term used in these large-scale assessments, are typically composed of sentences that are, in turn, organized inkhổng lồ paragraphs. These paragraphs are used to form larger structures such as stories, newspaper or magazine articles, & even sections or chapters in a book. A comtháng way of organizing continuous texts is by their rhetorical structure. These might include: narratives, exposition, description, argumentation, instructions, or a document and record. Noncontinuous texts or documents as they are referred to lớn involve sầu the display of information using other structures or formats. These might include tables, charts, graphs, entry forms, maps, và diagrams. They have sầu been described by Mosenthal and Kirsch (1998) and Kirsch (2001b). These materials range in both length and complexity. Some prose materials are very short such as a brief sports article or letter. Others are more lengthy và complex such as an editorial. Documents, too, range in length and complexity such as a social security card on which someone has to lớn enter their signature to lớn a complex table showing the results of a survey or an embedded bus schedule.
NALS scores were based on people”s ability khổng lồ accomplish tasks using printed texts. The difficulty of each task was related to three variables: type of match, type of information, & plausibility of distracting information (Kirsch, 2001a). Four types of matching strategies were identified: locating, cycling, integrating, và generating.
The tasks, in ascending order of difficulty, included:
Locating—requires the reader to lớn find information based on conditions or features specified in the text or document.
Cycling—requires the reader to lớn engage in a series of matching or locating operations that involve sầu the strategy of locating.
Integrating—requires the reader lớn pull together pieces of information from a text or document often times having to compare or contrast this information.
Generating—requires the reader khổng lồ produce a response either by making a text-based inference or by drawing on their background knowledge.
Formulating & Calculating—requires the reader khổng lồ identify both the numbers or quantities and the operation that must be performed. If more than one operation is required, the reader must determine the appropriate order of the operations.
Tasks were further identified by specific characteristics: type of match, type of information requested, plausibility of distracters, type of calculation, & operation specificity. Detailed discussions of how these factors contributed lớn scoring may be found in the International Adult Literacy Survey: Understanding What Was Measured (Kirsch, 2001b).
Findings reported participants” ability khổng lồ complete these tasks with 80 percent accuracy & consistency for three types of literacy: prose (tasks involving materials using full sentences in paragraph format), document (tasks involving materials consisting of lists, graphs, and charts), and numeracy (quantitative sầu literacy; tasks involving the application of basic mathematical processes). Assessments were scored on a 0 lớn 500 scale and findings were reported by score for various population groups and by levels:
Level 1 (score of 0 to lớn 225): Many adults at this cấp độ can perform tasks involving brief và uncomplicated texts và documents. Adults at this level can generally locate a piece of information in a news story or on a khung such as a social security card.
Level 2 (score of 226 khổng lồ 275): Adults at this level of proficiency are generally able khổng lồ locate information in text, make low-cấp độ inferences using printed materials, & integrate easily identifiable pieces of information.
Level 3 (score of 276 to 325): Adults at this cấp độ are able khổng lồ integrate information from relatively long or dense texts or documents, determine appropriate arithmetic operations based on information contained in the directive, and identify quantities needed lớn persize the operation.
Levels 4 (score of 326 lớn 375) và 5 (score of 376 lớn 500): Adults at these levels demonstrate proficiencies associated with long & complex documents & text passages.
Grade-Level Measures of Literacy
One of the most familiar terms associated with the assessment of reading levels is that of grade level. This term is used in two different ways. First, individual scores on assessments of reading achievement are often reported in terms of grade level, for example, He scored a Grade Equivalent (GE) of 5.2. The second way that grade level is used is to indicate the readability level of a text, for example, the story was written at a fifth grade màn chơi. The two uses of the term grade level, while related, do not mean the same thing. The first refers to lớn a norm-referenced score on a norm-referenced reading achievement kiểm tra and applies khổng lồ individuals. The second is the result of applying a formula for reading ease lớn written materials and applies to texts.
Grade-Level Ability for Individual Readers
Within the area of assessment và psychometrics, the construct of grade level indicates relative sầu placement of an individual or group score on a norm-referenced thử nghiệm, that is, a test designed so that an individual”s score can be established by comparison khổng lồ the chạy thử scores of a representative sầu sample of persons. Grade cấp độ is one type of transformed score. Others include percentiles, stanines, và standard scores. While these other transformed scores indicate specific locations on a bell-shaped normal curve of scores of a sample of previously tested individuals (the norm sample), grade-cấp độ scores bởi vì not, & therefore the potential for their misinterpretation is higher. Statistically, the grade-level score is derived from the mean score on a norm-referenced thử nghiệm. This means that the average raw score on a norm-reference achievement kiểm tra for a given grade is transformed inkhổng lồ the grade-màn chơi score for that grade. For example, if the average score attained by fifth graders in the norm sample on a norm-referenced reading achievement test, taken in the second month of fifth grade, is 75 (out of, say 100), then the score of 75 will be assigned a grade-level score of 5.2 (fifth year, second month). Therefore, one can say with accuracy that a student who scores on grade cấp độ is achieving, according to lớn this kiểm tra, on average. All other scores, both lower and higher, on this thử nghiệm are transformed into lớn grade-cấp độ scores through a process of mathematical extrapolation. Thus, a grade-màn chơi score (GE; grade equivalency) of 3.5 for a fifth grader on this demo indicates a certain distance below the average score; a GE of 7.2 correspondingly indicates a certain distance above sầu the average score. The appropriate interpretation of the on-grade-cấp độ, or average, score is as a measure of the student”s ability khổng lồ read material at his or her current grade cấp độ. Above-& below-grade-màn chơi scores are less reliable due to the extrapolation involved. This is due lớn their extrapolation from raw scores.
Studies that examined the reading ability of the intended audience, performed in the 1980s and early 1990s, frequently assessed reading ability with short-word recognition tests, Cloze tests (in which random words from a passage are deleted; Taylor, 1953), or other reading comprehension tests. These types of assessments of literacy typically result in the assignment of a grade-cấp độ score, & are frequently used by adult educators to lớn place adult students in appropriate level classes. One of these assessments, the reading recognition subkiểm tra of the Wide Range Achievement Test-Revised (WRAT-R) requires participants khổng lồ read aloud lists of words that become increasingly difficult. The chạy thử is stopped when 10 words have been consecutively mispronounced (Jastak & Wilkinson, 1984). The Instrument for Diagnosis of Reading, also known as the Instrumento lớn Para Diagnostical Lecturas (IDL), is another demo commonly used to lớn assess reading ability. Although the IDL is lengthy, taking more than 20 minutes to administer, it is useful because it was developed in the Spanish language & provides a comprehensive sầu assessment of reading comprehension in Spanish (Blanchard et al., 1989). A shortened size is available that takes about 7 minutes to administer.
Grade-Level Measures of Materials
Well over 300 articles in public health and medical journals focus on the assessment of various types of health-related materials (Roter et al., 2001; Rudd, 2003; Rudd et al., 2000). Many researchers used readability score lớn indicate text complexity. A commonly used formula for readability score is the Simplified Measure of Gobbledygook (SMOG) which is based on calculations of the number of polysyllabic words in a set number of sentences. Consequently, the SMOG focuses on sentence & word length, both of which are associated with reading ease or difficulty (McLaughlin, 1969). Other commonly used assessment measures include the Fry Readability Scale (Fry, 1977) and the Flesch-Kincaid Reading Grade Level (Flesch, 1974). Measures of reading levels probably required khổng lồ underst& different materials have contributed to lớn the retìm kiếm agendomain authority in health literacy by providing initial indications of text complexity, based on words & sentence length. These determinations of reading level are valuable when considered in light of the audiences for the material.
Measures of Health Literacy
Assessments of print literacy in the context of health were initially developed in the 1990s. Two frequently used assessments that have been described in detail are the Rapid Estimate of Adult Literacy in Medicine (REALM; Davis et al., 1993) and the Test of Functional Health Literacy in Adults (TOFHLA; Parker et al., 1995).
The REALM is a medical-word recognition & pronunciation thử nghiệm for screening adult reading ability in medical settings. It can be administered and scored in under 3 minutes by personnel with minimal training, making it easy lớn use in clinical settings. Participants read from a menu of 66 common medical terms that patients may be expected lớn be able lớn read in order to lớn participate effectively in their own health care. The words are arranged in three columns according to the number of syllables và pronunciation difficulty. Each correctly read & pronounced word increases the participant”s score by 1. Scores (0–66 words read and pronounced correctly) can be converted into four reading grade levels: grades 0–3 (0–18 words), grades 4–6 (19–44 words), grades 7–8 (45–60 words), & grade 9 và above sầu (61–66 words). The REALM”s criterion validity is established through correlation with other standardized reading tests: Peabody toàn thân Individual Achievement Test-Revised, 0.97 (Markwardt, 1989), Slosson Oral Reading Test-Revised, 0.96 (Slosson, 1990), & WRAT-R, 0.88 (Davis et al., 1993, 1998; all correlations p
The TOFHLA includes a 17-tác phẩm test of numerical ability và a 50-thắng lợi kiểm tra of reading comprehension, as measured by a Cloze procedure (see Appendix C for examples of items from the TOFHLA). The TOFHLA draws on materials commonly used in health-care settings at the time the chạy thử was developed. Reading passages were selected from instructions for preparation for an upper gastrointestinal series, the patient “Rights and Responsibilities” section of a Medicaid application, and a standard informed consent form. The numeracy items on the TOFHLA kiểm tra a patient”s ability to underst& monitoring blood glucose, keep a clinic appointment, obtain financial assistance, và understvà directions for taking medicines using an actual pill bottle.
Total scores for the TOFHLA are divided into lớn three criterion levels: inadequate, marginal, và adequate. Those with inadequate health literacy scores often misread medication dosing instruction, appointment slips, và instructions for the upper gastrointestinal tract radiographic procedure. Those with marginal health literacy scores persize better on those tasks, but often misread information on prescription bottles & have sầu trouble understanding the Medicaid “Rights và Responsibilities” passage. Those who score in the adequate range vì well on these tasks, but may have some difficulty comprehending the more difficult tasks like determining financial eligibility & the informed consent document (Parker et al., 1995). The TOFHLA takes up khổng lồ 22 minutes lớn administer & has good criterion validity, with correlation coefficients of r = 0.74 with the WRAT-R và r = 0.84 with the REALM, and a high reliability (Cronbach”s alpha = 0.98; Parker et al., 1995).
For time considerations, the TOFHLA was reduced to lớn an abbreviated version called the S-TOFHLA that takes 12 minutes or less lớn administer (Baker et al., 1999). It consists of a reading comprehension section containing a 36-công trình thử nghiệm using the initial two passages in the reading comprehension section of the full TOFHLA—instructions for preparation for an upper gastrointestinal series & the patient “Rights & Responsibilities” section of a Medicaid application. It also contains a shortened 4-nhà cửa measure of numeracy. The S-TOFHLA has been shown to lớn have good internal consistency reliability (Cronbach”s altrộn = 0.98 for all items combined) & concurrent validity compared lớn the long version of the TOFHLA (r = 0.91) and the REALM (r = 0.80). Both the TOFHLA và the S-TOFHLA are available in English and in Spanish. The Spanish và English versions were developed simultaneously và use the same standard of measurement.
Additional measures continue khổng lồ be developed, including a measure of health literacy in Veterans Administration hospital populations based on the S-TOFHLA (Chew và Bradley, 2003), a literacy chạy thử for patients with diabetes (Nath et al., 2001), và a functional test of ability to lớn maintain a medication regimen (Edelberg et al., 1998, 1999, 2001).
The use of these tests of literacy for printed material in the health context has enabled medical researchers khổng lồ explore differences among various health-related outcomes for patients based on approximations of patients” health literacy as indicated by patients” reading skills for health materials. As a result, a growing body toàn thân of retìm kiếm has shown that limited reading and/or numeracy skills reduce access khổng lồ health information & preventive services, reduce understanding of illness và disease, regimens & medications, and increase outcomes such as hospitalization or decrease outcomes such as disease management markers. This research is discussed in detail in Chapter 3.