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This study reflects the experiences of four Black women who succeeded in gaining their General Education Diploma. Their experiences in high school are a poignant example of the way in which talented youth are displaced in formal school settings. Their stories of learning to live with a minimum level of education provide the background for the study of their motivation to succeed. The twenty-seven interviews reveal the reasons for dropping out of high school, the situations that led to them returning to school, and the results of them staying on long enough to complete the General Education Diploma. Also, the participants reveal character traits that make their commitment to overcoming obstacles a strong feature of their journey to higher educational credentials. Through the lens of the women's determination to succeed in formal education we are able to understand the formidable odds that they have had to endure as Black, female, and literate in this society.

Storytelling provides a valuable link between generations within a family. It also provides an innovative approach to literacy instruction for adults and children. Descriptions are given of two methods of using stories within an intergenerational family literacy programme for English-as-a-Second Language families in the United States. Folk tales and family stories are used to build the links between oral and written language, and to provide a transition from personal texts to published texts. These stories also provide a vehicle for cultural transmission between generations, and an opportunity for bilingual language and literacy development. Suggestions are developed for using this approach in Adult Basic Education (ABE) classes in other countries, including South Africa. Storytelling can also be an effective tool to foster adult basic literacy in English and/or the mother tongue.

We describe the development of an abbreviated version of the Test of Functional Health Literacy in Adults (TOFHLA) to measure patients' ability to read and understand health-related materials. The TOFHLA was reduced from 17 Numeracy items and 3 prose passages to 4 Numeracy items and 2 prose passages (S-TOFHLA). The maximum time for administration was reduced from 22 minutes to 12. In a group of 211 patients given the S-TOFHLA, Cronbach's alpha was 0.68 for the 4 Numeracy items and 0.97 for the 36 items in the 2 prose passages. The correlation (Spearman) between the S-TOFHLA and the Rapid Estimate of Adult Literacy in Medicine (REALM) was 0.80, although there were important disagreements between the two tests. The S-TOFHLA is a practical measure of functional health literacy with good reliability and validity that can be used by health educators to identify individuals who require special assistance to achieve learning goals.

Adult literacy assessment is undergoing a shift from school-based achievement tests to functional literacy measures based on real-life tasks. Functional context assessment uses actual texts encountered by adults in their work, family life, church, and communities. Two examples of functional context assessment measures from the USA are presented: the National Adult Literacy Survey (NALS) and the Test of Functional Health Literacy in Adults (TOFHLA). Results from research studies using the NALS and TOFHLA and implications for South African adult basic education are presented. The introduction of the outcomes-based Independent Examination Board (IEB) Adult Basic Education and Training (ABET) examination system and the National Qualifications Framework (NQF) are discussed in the light of functional context assessment of adult literacy. Finally, concerns about the possible narrowing of ABET objectives and instruction resulting from the use of outcomes-based and functional context assessment are raised.

OBJECTIVES: This study examined the relationship of functional health literacy to self-reported health and use of health services. METHODS: Patients presenting to two large, urban public hospitals in Atlanta, Ga, and Torrance, Calif, were administered a health literacy test about their overall health and use of health care services during the 3 months preceding their visit. RESULTS: Patients with inadequate functional health literacy were more likely than patients with adequate literacy to report their health as poor. Number of years of school completed was less strongly associated with self-reported health. Literacy was not related to regular source of care or physician visits, but patients in Atlanta with inadequate literacy were more likely than patients with adequate literacy to report a hospitalization in the previous year. CONCLUSIONS: Low literacy is strongly associated with self-reported poor health and is more closely associated with self-reported health than number of years of school completed.

Objective : To describe what is known about the relation of literacy skills to contraceptive use and to suggest directions for future research. An overview of what is known about the literacy skills of Americans and the prevalence of inadequate functional health literacy is presented. Information about reading requirements for various methods of contraception and advice from health educators on dealing with low-literate populations are described. Data Sources : MEDLINE, PsychInfo, and ERIC searches for the last 20 years were completed using the terms literacy, literacy and health, family planning, health status, educational status, risk factors, contraception, and pregnancy. Methods of Study Selection : The primary literature searches identified 125 articles. After reviewing abstracts for these articles, we excluded 79 because they contained no specific mention of literacy or educational status relating to contraception. Tabulation, Integration, and Results : We were unable to identify any study specifically devoted to the relation between functional literacy and actual use of contraceptives. Forty-six with relevant background or related information were identified: literacy and health (19), adult literacy (nine), literacy and contraception (11), and literacy and family planning (seven). Over one-third of English-speaking and 62% of Spanish-speaking patients had inadequate or marginal functional health literacy in a study conducted at two urban public hospitals. Studies by health educators have demonstrated that information for many types of contraceptives is frequently above the patient's reading level. Available epidemiologic information on the relation between educational status and unplanned pregnancy is also presented. Conclusions : Although no study has specifically addressed how functional health literacy affects contraceptive use, it is reasonable to hypothesize that functional health literacy influences contraceptive knowledge, attitudes, and behaviors. Future research should focus on the relation between functional health literacy and actual use of various contraceptives.

Illiteracy is a well known national crisis, yet relatively little research has focused on how low literacy affects patients' health care experiences. The purpose of this study was to determine the relationship between shame and low functional literacy in the health care setting. It hypothesized that many patients with low literacy may not admit they have difficulty reading because of shame. Patients who presented for acute care at a large, public hospital in Atlanta, Georgia were interviewed. A total of 202 predominately indigent African-American patients completed a demographic survey, the Test of Functional Health Literacy in Adults (TOFHLA) and answered questions about difficulty reading and shame. Of the 202 patients interviewed, 42.6% had inadequate or marginal functional health literacy. Patients with low literacy were more likely to be male (P < 0.05), have less than a high school education (P < 0.01) and be over the age of 60 (P < 0.01). Of those patients with low literacy, 67.4% admitted having trouble reading and understanding what they read. Almost 40% (n = 23) of patients with low functional literacy who acknowledged they have trouble reading admitted shame. Of the 58 patients who had low functional health literacy and admitted having trouble reading, 67.2% had never told their spouses, and 53.4% had never told their children of their difficulties reading. Nineteen percent of patients had never disclosed their difficulty reading to anyone. Many patients with reading problems are ashamed and hide their inability to read. Shame is a deeply harbored emotion that plays an important role in understanding how low literate patients interact with health care providers. Further research is needed to understand how providers should deal with the shame associated with low literacy.

Child care centers are serving an increasing number of children of adolescent parents. Providing a social support network and parenting education for these parents is important to the development of both the children and their parents. Successful family support intervention programs are reviewed and implications for child care programs are presented.

OBJECTIVE: To develop a valid, reliable instrument to measure the functional health literacy of patients. DESIGN: The Test of Functional Health Literacy in Adults (TOFHLA) was developed using actual hospital materials. The TOFHLA consists of a 50-item reading comprehension and 17-item numerical ability test, taking up to 22 minutes to administer. The TOFHLA, the Wide Range Achievement Test-Revised (WRAT-R), and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered for comparison. A Spanish version was also developed (TOFHLA-S). SETTING: Outpatient settings in two public teaching hospitals. PATIENTS: 256 English- and 249 Spanish-speaking patients were approached. 78% of the English- and 82% of the Spanish-speaking patients gave informed consent, completed a demographic survey, and took the TOFHLA or TOFHLA-S. RESULTS: The TOFHLA showed good correlation with the WRAT-R and the REALM (correlation coefficients 0.74 and 0.84, respectively). Only 52% of the English speakers completed more than 80% of the questions correctly. 15% of the patients could not read and interpret a prescription bottle with instructions to take one pill by mouth four times daily, 37% did not understand instructions to take a medication on an empty stomach, and 48% could not determine whether they were eligible for free care. CONCLUSIONS: The TOFHLA is a valid, reliable indicator of patient ability to read health-related materials. Data suggest that a high proportion of patients cannot perform basic reading tasks. Additional work is needed to determine the prevalence of functional health illiteracy and its effect on the health care experience.

Des recherches britanniques sur des parents ecoutant leurs enfants lire a haute voix, ont indique que cette activite est une facon effective de developper le niveau de lecture des enfants d’ecoles primaires. Apres quelques modifications l’approche britannique a ete implantee dans une ecole americaine en zone urbaine dont les effectifs venaient de milieux socio-economiques defavorises. Des livres ont ete envoyes periodiquement aux familles avec des exercices de lecture journaliers pendant une periode de 10 semaines. Les parents ecoutaient leurs enfants lire et renvoyaient periodiquement une carte signee. La participation etait recompensee. La participation au programme a ete elevee. Des entretiens avec les instituteurs et les parents ont indique que l’experience avait ameliore l’enthousiasme des enfants et leurs interets pour la lecture. Les parents avaient aussi une meilleur conaissance des progres de leurs enfants. Les progres des enfants participants ont ete significatifs a tout les niveaux de lecture de l’ecole. Le projet a ete si bien recu qu’il a ete adopte par l’ecole et la communaute et est dorenavent inclus dans le programme de l’ecole.

Inadequate functional health literacy is common, but its impact on patients with chronic diseases is not well described.To examine among patients with hypertension or diabetes the relationship between their functional health literacy level and their knowledge of their chronic disease and treatment.We conducted a cross-sectional survey of patients with hypertension and diabetes presenting to the general medicine clinics at 2 urban public hospitals. Literacy was measured by the Test of Functional Health Literacy in Adults. Knowledge of their illness was assessed in patients with diabetes or hypertension using 21 hypertension and 10 diabetes questions based on key elements in educational materials used in our clinics.A total of 402 patients with hypertension and 114 patients with diabetes were enrolled. Mean (+/- SD) knowledge scores for patients with hypertension with inadequate (n = 189), marginal (n = 49), or adequate (n = 155) literacy were 13.2 +/- 3.1, 15.3 +/- 2.2, and 16.5 +/- 2.3, respectively (range, 4-20; P.001). A total of 92% of patients with hypertension and adequate literacy levels knew that a blood pressure reading of 160/100 mm Hg was high compared with 55% of those in the lowest reading level (P.001). Mean (+/- SD) knowledge scores for patients with diabetes with inadequate (n = 50), marginal (n = 13), or adequate (n = 51) literacy were 5.8 +/- 2.1, 6.8 +/- 1.9, and 8.1 +/- 1.6, respectively (range, 1-10; P.001). A total of 94% of patients with diabetes and adequate functional health literacy knew the symptoms of hypoglycemia compared with 50% of those with inadequate literacy (P.001).Inadequate functional health literacy poses a major barrier to educating patients with chronic diseases, and current efforts to overcome this appear unsuccessful.

Functional health literacy was assessed in 63 patients from the diabetes outpatient clinic, 20 from the general medicine clinic, and a total of 48 from two satellite medical clinics. All patients received a demographic questionnaire, visual screening, and the Test of Functional Health Literacy in Adults, an instrument with good validity and internal consistency used to measure the ability to read and understand medical instructions. Functional health literacy was adequate in only 47% of new patients at the diabetes clinic and only 25% of established patients at all sites. There were no significant differences in functional health literacy among established patients across all sites. Overall, patients' mean functional health literacy level was inadequate to marginal. Of the patients with inadequate functional health literacy, 43%, denied difficulty in reading. Patient education strategies and materials are needed to address this important barrier to healthcare delivery.

In Reply. —Drs Gottesman and Kelly raise an interesting question about the root causes of low literacy. We agree that some people who have low literacy skills may have specific learning disabilities (eg, dyslexia) that prevented them from learning to read. However, we believe the vast majority of the problem stems from lack of access to education or poor-quality education during critical developmental periods. The higher prevalence of low literacy among older adults and Spanish-speaking patients, many of whom were unable to go to school or attended schools with very poor facilities, supports this explanation and argues against learning disabilities as the dominant cause. Labeling low literacy as a learning disability is also extremely dangerous because many children from racial and ethnic minorities in the United States have been cast aside into "handicapped" classes because their language abilities were behind their peers. Nevertheless, we agree that many patients with low

Objective. —To determine the ability of patients to complete successfully basic reading and numeracy tasks required to function adequately in the health care setting. Design. —Cross-sectional survey. Setting. —Two urban, public hospitals. Patients. —A total of 2659 predominantly indigent and minority patients, 1892 English-speaking and 767 Spanish-speaking, presenting for acute care. Main Outcome Measure. —Functional health literacy as measured by the Test of Functional Health Literacy in Adults (TOFHLA), an instrument that measures ability to read and understand medical instructions and health care information presented in prose passages and passages containing numerical information (eg, prescription bottle labels and appointment slips). Results. —A high proportion of patients were unable to read and understand written basic medical instructions. Of 2659 patients, 1106 (41.6%) were unable to comprehend directions for taking medication on an empty stomach, 691 (26%) were unable to understand information regarding when a next appointment is scheduled, and 1582 (59.5%) could not understand a standard informed consent document. A total of 665 (35.1%) of 1892 English-speaking patients and 473 (61.7%) of 767 Spanish-speaking patients had inadequate or marginal functional health literacy. The prevalence of inadequate or marginal functional health literacy among the elderly (age ≥60 years) was 81.3% (187/230) for English-speaking patients and 82.6% (57/69) for Spanish-speaking patients, and was significantly higher ( P Conclusions. —Many patients at our institutions cannot perform the basic reading tasks required to function in the health care environment. Inadequate health literacy may be an important barrier to patients' understanding of their diagnoses and treatments, and to receiving high-quality care. ( JAMA . 1995;274:1677-1682)

A study of contemporary kindergarten children's toy preferences indicated that they were as rigidly stereotyped by sex as those of children of previous decades. In view of social and legal changes and growing professional concerns about sex-role stereotyping, the authors present implications of sex-typed play and offer suggestions for combatting stereotyping and sex discrimination.

In 1985–1987 observations2 were made in kindergartens in Scandinavia (Norway, Sweden, Denmark), Great Britain, and the United States. Based upon these observations, the written language environments are described and comparisons are made. In Scandinavia, the kindergartens for 6-year-olds are generally environments that emphasize social development, oral language, and creative expression through play. Essentially no written language is found. In Great Britain (and in British schools elsewhere), the same interactive play environment also includes written language. Five-year-olds in the reception class of the infant, or first school are introduced to reading within the context of story books and to writing via story dictation and copying. In the United States, public school kindergartens for 5-year-olds have become increasingly more academic over the past 25 years. However, some developmentally appropriate kindergartens still exist many of which include a print-rich, written language environment in which the 5-year-olds acquire written language naturally. Current research from several cultures suggests that a natural use of written language as a part of children’s social play environment might be a valuable addition to the kindergarten programs in all of these countries.

Five language-eliciting situations were presented to 48 kindergarten and primary-grade children to identify developmental trends and task effects in the complexity of language structures, vocabulary, functions, and story conventions used. Limited developmental differences (between kindergarten and primary children but not within primary groups) were found. Significant task effects were found. Telling an original story with no picture stimulus produced the most mature language structures and functions; the wordless picture book task elicited more mature narrative structures; and the single picture tasks elicited more varied vocabulary. Classroom instructional implications are suggested.

The purpose of this study was to analyze the language of eight 4-year-old children from two day care centers as they described a picture and told a story from pictures in a wordless picture book. The children's oral language was analyzed for vocabulary, syntax, completeness, and accuracy. Their stories were assessed for Ap- plebee's narrative conventions and structure. Comprehension of the picture and the book was assessed by questions. The children's descriptions and stories, although short, contained a variety of vocabulary words and an above average number of words per T-unit for their age. However, their stories did not contain any narrative conventions nor did the children demonstrate that they had achieved a sense of the story. The children's descriptions were only partially accurate, and they demonstrated limited comprehension of the picture and story. These results are discussed in relation to the day care and pre-school language curriculum and environ- ment. Implications are drawn for the children's prereading development and their readiness for beginning reading instruction. Prereading development is fostered by children's oral language fluency, listen- ing comprehension, wide experiences with books, and an interest in printed words found in their environment. A faciiitative prereading environment gives children op- portunities to look at books, to hear stories read, to tell stories, to see printed labels and words, and to engage in functional reading of environmental words such as their names or logos for popular products. It also allows them to experiment with scribbl- ing and writing and to receive adult feedback and interaction with both oral and writ- ten language (Teale, 1978). Does day care provide this type of an environment for developing a child's language and prereading skills? Relatively little information is available in the literature to answer that question. In recent reviews of day care research, Belsky and Steinberg (1978) and Etaugh (1980) noted that most day care studies consider only short-term social, emotional, and cognitive effects of day care on very young children (often infants) in high quality university-based centers. Belsky and Steinberg concluded that "with regard to children's intellectual development, the

Nurss, J. R. 1988. Development of Written Communication in Norwegian Kindergarten Children. Scandinavian Journal of Educational Research 32, 33‐48 Forty‐eight Norwegian kindergarten children with ages ranging from 3 to 6 years drew pictures, wrote their names, and wrote a caption under their pictures three times during one school year. Their written language was rated on a 0 to 8 point scale. The results showed strong age‐related developmental trends and some within‐age group growth over the school year. No gender‐related differences were found. Six‐year‐olds also read common logos and the same word in decontextualized print. The language/ print environment of the classrooms was evaluated. Results are compared with those of other studies in several different cultures and are discussed in relation to Norwegian kindergarten philosophy and curriculum. 1The research described in this article was completed while the author was fulbright Professor at the Institute of Education, University of Trondheim/...

Tape recordings were made of six white and six black ninth-grade northern boys speaking identically worded answers to typical school questions. Black students were given significantly higher grades than white students by 56 white and 50 black southern teachers. Black teachers gave significantly higher grades than white teachers, but no significant interaction was found between students' and teachers' ethnic group. The study is a partial replication of a previous study in which it was found that black students were given significantly lower grades than white students by northern white teachers.

The purpose of the study was to gather baseline data from 147 Southern urban higher status white and lower status white and black 4-year-old boys and girls on measures of their ability to imitate, comprehend, and produce selected grammatical structures. The children were given the Brown, Fraser, Bellugi Test of Grammatical Contrasts. The higher status white group performed significantly better on all three tasks than did either of the lower status groups. The tasks ordered in difficulty: comprehension = imitation > production. An alternate scoring system was devised to account for possible dialect differences between the test and the lower status children.

guage deficiencies into account. If a child cannot use school language to express ideas clearly and with ease, he is not likely to meet the expectations schools place on him. If one intervenes early enough in the lives of lower-status children, changes in language can be effected. To this end, eight classes of innercity, lower-status, threeto fouryear-old pre-kindergarten children in Atlanta, Georgia, were given ten months' instruction to increase their

The trend toward a growing proportion of American women employed outside the home is clear. One- and two-parent families, often out of economic necessity, are seeking alternative care arrangements for their infants and preschool-aged children. As many are experiencing full-day, alternative child care during part or all of their developmentally crucial first five years, there is a need to focus on the quality of day care. Several recent reviews of center-based day care research have portrayed this experience as a relatively benign influence on the development of young children provided that a high level of quality is maintained (Belsky & Steinberg, 1978; Bronfenbrenner, 1979; Etaugh, 1979). What are the implications of this research for child care providers? If it is true that high quality child care has a benign effect on young children's development, what can child care providers do to ensure quality care?

INVESTIGATES WHAT EACH of the tests in a battery of 53 perceptual, cognitive, linguistic, and achievement measures was assessing in two socio-economic level (SEL) groups: upper-middle and low. Subjects were 211 second-grade boys and girls from the Atlanta Public Schools, approximately one third black and two thirds white from each SEL. Separate intercorrelation matrices and factor analyses were computed for the two SEL groups. Several well-defined factors common to both groups were found: immediate memory span, academic achievement, vocabulary, and four visual-perceptual factors. A separate auditory processing factor was found for the low SEL group and a verbal mediation factor for the upper-middle SEL group. The greatest similarity between the two SEL groups seemed to be in the visual factors and the greatest difference in the language factors. Implications were made about use of some of the tests and about teaching reading to Southern upper-middle and low SEL children.