Public Health Functional Literacy
by
John P. Comings
  • LAST REVIEWED: 15 June 2015
  • LAST MODIFIED: 23 February 2011
  • DOI: 10.1093/obo/9780199756797-0032

Introduction

Literacy comprises a set of skills (usually listed as phonics, decoding, fluency, vocabulary knowledge, and comprehension) and a set of practices (employing all of these skills to accomplish tasks with text). The term “functional literacy” came into common use in the 1960s, when the United Nations Educational, Scientific, and Cultural Organization (UNESCO) began addressing the lack of literacy skills among a large percentage of the population of adults and out-of-school children in developing countries. At the time, literacy experts were concerned that the teaching of literacy in developing countries was focused solely on skills and needed a greater focus on practices. This concern led to UNESCO’s emphasis on literacy being taught as a functional skill, and literacy instruction consistent with this approach was referred to as functional literacy. The term became associated with a definition of literacy as a functional skill. The field of public health is interested in functional literacy for two reasons. First, public health professionals are increasingly aware that low functional literacy is a barrier to health communications; and second, the National Institutes of Health’s National Institute for Child Health and Development now urges pediatricians to pay attention to the literacy development of their patients. This article identifies sources that help public health professionals understand functional literacy and approaches to assessing it from the point of view of literacy scholars, and this provides a foundation for understanding the use of this term in public health. It is important for public health professionals to understand how literacy is defined and measured, in particular because of a growing interest in health literacy.

Definitions

The term “functional literacy” is used in three different contexts: international discussions, adult literacy, and general education. Though the definitions are similar, each might be more appropriate for a specific public health purpose. UNESCO defines it as the level of skill needed to function fully in society in international discussions. Jarvis 1999 defines it the same way for adult education settings. Collins and O’Brien 2003 provides the same definition but offers an alternative that sees functional literacy as the minimum needed to meet personal and social needs in general education. Guzzetti, et al. 2002 provides a short history of the development of the term.

  • Collins, John W., III, and Nancy Patricia O’Brien, eds. 2003. The Greenwood dictionary of education. Westport, CT: Greenwood.

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    The definition on p. 148 is also drawn from that of the UNESCO Institute of Statistics, but this source is more commonly used in the general education literature. In addition, this source offers an alternative definition of functional literacy as a minimum level of skill.

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    • Guzzetti, Barbara J., Donna E. Alvermann, and Jerry L. Johns, eds. 2002. Literacy in America: An encyclopedia of history, theory, and practice. Santa Barbara, CA: ABC-Clio.

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      Under the heading “Adult Literacy” on p. 19, this source provides a history of the development of the definition of functional literacy, from its first use in the 1940 US Census through its use as a measurement objective in the 1992 National Adult Literacy Survey.

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      • Jarvis, Peter. 1999. International dictionary of adult and continuing education. 2d ed. London: Kogan Page.

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        The definition on p. 75 of this dictionary is drawn from that of the UNESCO Institute of Statistics, but this source is more commonly used in the literature of adult education. In addition, this definition is more concise.

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        • UNESCO Institute for Statistics. Functional Literacy.

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          The definition employed by the UNESCO Institute for Statistics sees functional literacy as a level of reading, writing, and calculation skills sufficient to function in the particular community in which an individual lives. The UNESCO definition is useful in international discussions of functional literacy.

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          Background

          Functional literacy is a subcategory of literacy. Public health professionals who want to understand literacy should have a basic understanding of what it is, how it is acquired and improved, and what the term means when employed by professional literacy educators. The resources in this section provide an introduction to literacy that serves as a foundation for understanding research and scholarship about functional literacy. Snow, et al. 1998 focuses on why children develop reading difficulties and ways to prevent and address those difficulties. Snow and Strucker 1999 explores the relevance of those findings for adults. National Reading Panel 2000 reviews the experimental and quasi-experimental research or reading. Adams 2001 resolves the debate between two major approaches to reading instruction—phonics and whole language. Ong 1988 analyzes the literature on the differences between oral and written communications. LeVine, et al. 1994 synthesizes the findings from studies on the effects of literacy skill on the health and family planning behaviors of mothers in rural Mexico, rural Nepal, and urban Zambia, finding a positive relationship and a possible explanation for that relationship. McCardle and Chhabra 2004 presents the state of evidence-based practice in reading instruction. Ginzburg, et al. 2006 identifies the components of numeracy by reviewing the most commonly cited instructional frameworks.

          • Adams, Marilyn Jager. 2001. Beginning to read: Thinking and learning about print. Cambridge, MA: MIT Press.

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            Anyone venturing into literacy will hear about the “reading wars.” This book provides a description of the war and resolves the debate between the two sides, phonics and whole language. Discussions of functional literacy often refer to this debate, and this balanced view of the argument is now the accepted view of most literacy experts.

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            • Ginsburg, Lynda, Myrna Manly, and Mary Jane Schmitt. 2006. The components of numeracy. NCSALL Occasional Paper. Cambridge, MA: National Center for the Study of Adult Learning and Literacy.

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              This monograph identifies the components of numeracy and the types of numeracy practices common to adult life. This approach is consistent with the sources in this section that focus on literacy, and therefore it expands the background understanding of functional literacy.

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              • LeVine, Robert, E. Dexter, P. Velasco, Sarah LeVine, Arun Joshi, Kathleen Sruebing, and F. Tapia-Uribe. 1994. Maternal literacy and health care in three countries: A preliminary report. Health Transition Review 4.2: 186–191.

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                This review of several studies helps explain why there are differences related to health care access between adults with low and high literacy skills. This understanding of the impact of functional literacy skills on oral communications builds a deeper understanding of how functional literacy and health communications are linked.

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                • McCardle, Peggy, and Vinita Chhabra, eds. 2004. The voice of evidence in reading research. Baltimore: Paul H. Brookes.

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                  Evidence-based practice and random assignment experiments are relatively new activities in education, but some of the most productive work has been focused on literacy. This book provides both an overview and details of methods (including neuroimaging of the brain) and findings.

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                  • National Reading Panel. 2000. Teaching children to read: An evidence-based assessment of the scientific research literature on reading and its implications for reading instruction. Washington, DC: National Institutes of Health.

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                    This report provides access to all of the experimental and quasi-experimental research literature available at the time of preparation. Most literacy instruction is now based on the findings in this report. The NRP website provides detailed reports of the work of its subcommittees as well as a video that explains its main findings.

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                    • Ong, Walter J. 1988. Orality and literacy: The technologizing of the word. London: Routledge.

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                      This book (first published in 1982 and frequently reprinted) helps readers to understand more clearly the differences between the communications made by preliterate and literate societies, and this understanding provides insights into why and how oral communications difficulties might arise between adults with low literacy skills and health professionals who have high literacy skills.

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                      • Snow, Catherine E., M. Susan Burns, and Peg Griffin, eds. 1998. Preventing reading difficulties in young children. Washington, DC: National Academy Press.

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                        This book provides a comprehensive understanding of how literacy is acquired by children and the factors that can lead to reading difficulties. This provides a good background for public health professionals to understand how to help parents and schools prevent reading difficulties and address them when they do occur.

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                        • Snow, Catherine E., and John Strucker. 1999. Lessons from preventing reading difficulties in young children for adult learning and literacy. In Annual review of adult learning and literacy. Vol. 1. Edited by John Comings, Barbara Garner, and Cristine Smith, 25–73. San Francisco: Jossey-Bass.

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                          This chapter explains how reading difficulties that occur in childhood manifest themselves in adults. It also presents six case studies of adults with low literacy skills. The chapter builds an understanding of the multiple reasons why adults may have low functional literacy skills. Available online.

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                          Journals

                          Three journals regularly publish articles related to functional literacy. Reading Research Quarterly is published by the International Reading Association and presents research on early childhood, school, and adult reading. Adult Basic Education and Literacy Journal is published by the Commission on Adult Basic Education (COABE) and ProLiteracy and publishes research on adult literacy. TESOL Quarterly is published by the Teachers of English to Speakers of Other Languages and presents research on English-language learning, including the learning of English literacy by immigrants in English-speaking countries.

                          Assessment

                          Assessments of functional literacy can measure individual component reading skills, such as vocabulary or fluency, or practices, such as those involved in work or the activities of everyday life (referred to as “document literacy”), and those that are represented in fiction, nonfiction, and journalism (referred to as “prose literacy”). Though some public health research uses literacy assessment methods developed by health experts, large-scale assessments of functional literacy and most research on literacy use methods developed in the field of education. Public health professionals and researchers may need a better understanding of these educational assessment methods to draw from sources that employ them. Kruidenier 2002 reviews the history of literacy assessment and examines the approaches and tools employed in it. Van Duzer and Berdan 1999 reviews the approaches and tools used to assess the literacy skills of immigrants in the United States who are not fluent speakers of English. Mosenthal and Kirsch 1998 describes an approach to measuring the readability of document samples employed in assessment. Strucker, et al. 2007 explains the five levels of the International Adult Literacy Survey in terms of the reading component skills of the subjects.

                          • Kruidenier, John. 2002. Literacy assessment in adult basic education. In Annual review of adult learning and literacy. Vol. 3. Edited by John Comings, Barbara Garner, and Cristine Smith, 84–151. San Francisco: Jossey-Bass.

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                            This chapter provides a comprehensive overview of assessment approaches and tools. This can be useful in understanding studies that employ them. The chapter is also useful in evaluating studies in public health that employ assessment tools developed for the field, and provides a way to learn the vocabulary of literacy assessment. Available online.

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                            • Mosenthal, Peter, and Irwin Kirsch. 1998. A new measure for assessing document complexity: The PMOSE/IKIRSCH document readability formula. Journal of Adolescent and Adult Literacy 41:638–657.

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                              This article explains a useful document readability formula, and it helps to explain how the difficulty of document samples for functional literacy assessments is determined. This provides a much clearer understanding of how large-scale assessments are useful to public health applications, which employ many complex documents.

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                              • Strucker, John, Kentaro Yamamoto, and Irwin Kirsch. 2007. The relationship of the component skills of reading to IALS performance: Tipping points and five classes of adult literacy learners. Cambridge, MA: National Center for the Study of Adult Learning and Literacy.

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                                This research sheds light on why adults might fall into one of the five literacy levels identified by the International Adult Literacy Survey and identifies the specific barriers to written communications for adults at each level.

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                                • Van Duzer, Carol H., and Robert Berdan. 1999. Perspectives on assessment in adult ESOL instruction. In Annual review of adult learning and literacy. Vol. 1. Edited by John Comings, Barbara Garner, and Cristine Smith, 200-242. San Francisco: Jossey-Bass.

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                                  Since immigrants are an important public health target group, assessing their functional literacy skills may be important in some public health situations. This chapter provides a good background on the assessment issues, approaches, and tools used to assess functional literacy skills in immigrant populations in the United States. Available online.

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                                  National and International Assessments

                                  Since the mid-1980s, several countries have implemented national assessments that administer tests to a sample of their populations to assess levels of functional literacy. These assessments have employed a similar methodology so that cross-national comparisons can be made. Sticht and Armstrong 1994 describes the large-scale assessments of the functional literacy skills of US adults that took place between 1917 and 1993. Comings and Kirsch 2005 provides an overview of the international assessments over the preceding twenty-five years. Kirsch, et al. 1993 presents the initial findings from the 1992 National Adult Literacy Survey (NALS) in the United States. Organization for Economic Co-operation and Development and Statistics Canada 1995 describes the International Adult Literacy Assessment (IALS), which took place in seven countries in North America and Europe. Murray, et al. 1998 describes the technical aspects of the IALS. Kirsch 2001 describes how the IALS questions were constructed. National Center for Education Statistics 2005 reports the initial findings of the 2003 National Assessment of Adult Literacy (NAAL) in the United States. National Center for Education Statistics 2006 describes the technical aspects of the NAAL.

                                  Tools to Assess Skills of Populations

                                  The first analysis of population-based health literacy skills among adults was based on the 1992 National Adult Literacy Survey. Rudd, et al. 2004 reports on health literacy skills based on 191 health-related items identified in the 1992 survey and coded into one of five health activity categories. The coding and the latent class analyses model supported an approach to assessing health literacy skills of adults within and across countries that participated in the international surveys. Australian Bureau of Statistics 2006 reports on health literacy in Australia, and Murray, et al. 2007 subsequently reports on health literacy in Canada. These two studies were based on the Adult Literacy and Lifeskills Survey (ALLS), and Rudd, et al. 2004 had previously coded all health-related items. The analysis of the 236 health items from the ALLS provided measures for health literacy in these two countries, as well as portraits of population groups with high and low scores. Separately, the US Department of Health and Human Services worked with the Department of Education to insert twenty-eight specific health-related items in the 2003 follow-up to the 1992 NALS. Kutner, et al. 2006 reports on health literacy of US adults based on responses to these items.

                                  • Australian Bureau of Statistics. 2006. Health literacy, Australia. Publication 4233.0. Canberra: Australian Bureau of Statistics.

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                                    The scores for health literacy among Australians is derived from the HALS analytic process applied to the Adult Literacy and Lifeskills Survey. Findings provide a portrait of health literacy in Australia and indicate that, overall, about half of Australian adults have difficulty using health materials with accuracy and consistency.

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                                    • Kutner, Mark, Elizabeth Greenberg, Ying Jin, Christine Paulsen, and Sheida White. 2006. The health literacy of America’s adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006-483. Washington, DC: National Center for Education Statistics.

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                                      The average scores reported for the NAAL health literacy measure are lower than those for general literacy among adults. Findings indicate that many US adults do not have the skills to effectively use health materials to accomplish many challenging or complex health-related literacy tasks.

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                                      • Murray, Scott, Rima Rudd, Irwin Kirsch, Kentaro Yamamoto, and Sylvie Grenier. 2007. Health literacy in Canada. Ottawa, ON: Canadian Council on Learning.

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                                        Applying the HALS analysis for the ALLS 2003 survey, the authors report on health literacy proficiencies among Canadians and analyze public policy implications. Health literacy scores vary by province and territory. Overall, more than half of Canadian adults have difficulty using commonly available health materials to accomplish health-related tasks.

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                                        • Rudd, Rima, Irwin Kirsch, and Kentaro Yamamoto. 2004. Literacy and health in America. Princeton, NJ: Educational Testing Service.

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                                          The HALS analysis of 191 coded health items from the NALS offers evidence that average proficiencies in the United States are below par. Latent group analyses indicate links between limited health literacy and compromised health status, limited engagement in civic activities, and reduced access to health information.

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                                          Literacy Practices

                                          The study of literacy practices is less developed than the study of the component skills of literacy. Most of the literature is based on anthropological and linguistic studies of how adults use literacy in daily life. Though some of this work is meant to broaden the view of literacy within the education sector, it also provides a different perspective on literacy that could provide insights into how public health communications could be more effective. In addition, some recent work has focused on the impact of technology on the practice of literacy and on the relationship between skills and practices. Street 1993 was the first major work to bring together different perspectives on how functional literacy might be different in different contexts. Barton, et al. 2000 builds on earlier work by providing case studies of functional literacy in different contexts. Silver-Pacuilla and Reder 2008 reviews the research on how literacy and language skills, access, and support affect online learning of adults with low functional literacy. Reder and Bynner 2009 describes the findings of longitudinal studies of low-literacy adults in the United States and the United Kingdom. Silver-Pecuilla 2007 describes how assistive technology can help adults with low functional literacy to understand written materials and communicate in writing in ways that also assist the improvement of their skills.

                                          • Barton, David, Mary Hamilton, and Roz Ivanic, eds. 2000. Situated literacies: Reading and writing in context. London: Routledge.

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                                            This book presents cases studies of literacy in different contexts, some of which may be of interest to public health professionals. In addition, the book expands the concept of functional literacy to be more than just text and tasks and to include the social context of literacy.

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                                            • Reder, Stephen, and John Bynner. 2009. Tracking adult literacy and numeracy skills: Findings from longitudinal research. New York: Routledge.

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                                              Very few longitudinal studies have looked at adults with low functional literacy. This book brings together studies from the United States and the United Kingdom. Public health professionals can learn from the findings of these studies, but they can also learn from the research methodologies employed.

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                                              • Silver-Pecuilla, Heidi. 2007. Assistive technology and adult literacy: Access and benefits. In Review of adult learning and literacy. Vol. 7. Edited by John Comings, Barbara Garner, and Cristine Smith, 93–136. Mahwah, NJ: Erlbaum.

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                                                Public health professionals are trying to make their written materials easier to understand. This chapter suggests that assistive technology could help make improved and unimproved materials more accessible to adults with low functional literacy.

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                                                • Silver-Pacuilla, Heidi, and Stephen Reder. 2008. Investigating the language and literacy skills required for independent online learning. Washington, DC: National Institute for Literacy.

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                                                  Public health communications is moving online. Since functional literacy skill level may play a part in how well someone can use the online environment for learning, this report can be helpful in designing a support system that makes it easier for those with low skill levels.

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                                                  • Street Brian V., ed. 1993. Cross-cultural approaches to literacy. Cambridge, UK: Cambridge Univ. Press.

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                                                    This book challenges the contention that literacy is a single, uniform skill and presents it as many different practices that vary from one context to another. Public health communications is a particular context that may present barriers separate from readability.

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                                                    Adult and Child Literacy

                                                    Online resources provide access to sources of research and information that is not available in other forms. Some of these sources are focused on both child and adult, literacy, while some are focused only on either child literacy or adult literacy. The National Institute for Literacy is focused on literacy across the lifespan. The International Reading Association is focused on all aspects of reading, and though it is a US-based organization, it has an international membership. TESOL is focused on all aspects of English-language learning, including reading. The National Reading Panel is focused on the acquisition of literacy skills by children in schools, as well as home and community supports for literacy learning. The UNESCO Institute for Lifelong Learning is focused on adult learning, including literacy, in all countries of the world. The National Center for the Study of Adult Learning and Literacy is focused on adults with low literacy skills. The National Adult Literacy Database is focused on both English-speaking and French-speaking low-literacy adults in Canada. The National Research and Development Centre for Adult Literacy and Numeracy is focused on low-literate adults in the United Kingdom.

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