Does literacy have an effect on stick construction tasks?

Illiteracy, Neuropsychological Assessment, and Cognitive Rehabilitation: A Narrative Review

OBJECT

Νeuropsychological assessment is particularly important for the accurate discrimination of cognitive abilities and weaknesses of patients in order to determine the appropriate therapeutic intervention. However, the reliability and validity of neuropsychological assessment appears to be influenced by a wide range of factors, including literacy and educational level.

AIM

This systematic review evaluates neuropsychological tests appropriate for the valid assessment of illiterate individuals and the effectiveness of cognitive rehabilitation programs for illiterate and/or low-educated individuals according to the results of English language studies that have been published in the PubMed/Medline electronic database until August 2022 (no initiation date).

RESULTS

49 studies were included for neuropsychological assessment and 4 studies for cognitive rehabilitation. In terms of investigating the validity and reliability of neuropsychological tests for the assessment of healthy illiterate individuals, most studies concluded that for the majority of neuropsychological tests there is a significant difference in performance between healthy illiterate and literate individuals. However, there was consensus among studies that the performance of illiterate subjects was equivalent to the performance of literate subjects on tasks depicting colored and real objects. Regarding cognitive rehabilitation programs, all four studies concluded that they are effective in improving the cognitive functions of illiterate and/or low-literate patients with mild cognitive impairment and/or mild dementia.

CONCLUSIONS

For the assessment of illiterate individuals, it is imperative that neuropsychological tests with high ecological validity (i.e., tests related to activities of daily living) be administered so as not to underestimate their cognitive functioning. At the same time, cognitive enhancement/stimulation programs seem to be effective in this population group; however, this area needs further investigation.

User Experience of the Mobile Terminal Customization System: The Influence of Interface Design and Educational Background on Personalized Customization

The study verified the role that different interface designs and users’ educational backgrounds play in the task performance and subjective evaluation of mobile terminal customization system. Interface type (based on scroll, alternative, and attribute) and user group (college students and industrial workers) were employed as the variables. A total of 72 users were included in the study, and an analysis of 3 × 2 between-participants design indicated that (1) Different interface designs of customization systems had a significant difference in task performance, the alternative based interface had the best results in the task performance, and there was no significant difference between the attribute-based and scroll-based interfaces in task performance; (2) The matching between educational background and interface type will affect the users’ evaluation on system usability. Industrial workers thought that the scroll-based and alternative-based interfaces were more useable, while college students preferred attribute-based interface design; (3) Different interfaces had a significant difference in user task load. The scroll-based interface had the lowest mental demand on the users, while alternative-based had the lowest physical demand on the users, though it consumed more effort; (4) Different educational backgrounds had a significant difference in user task load. Industrial workers showed lower effort in the scroll-based and alternative-based interfaces, while college students had lower effort in the attribution-based interface; (5) A correlation analysis showed that there was a significant negative correlation between the system usability score and the effort in task load. This study results have a positive significance for interface design. With educational background and layout as two important factors in our interface design, we may obtain the most appropriate design principles for enhancing the online customization experiences of different groups of consumers. The more important is that this study is based on the actual needs of the industry. For the first time, we take suitcase as an online customized product, which may not only help local manufacturers to extend their traditional offline distribution channels to online, but also provide a constructive thinking concerning interface design for customization of a single product.

Evaluation of sensitivity and specificity of the INECO Frontal Screening and the Frontal Assessment Battery in mild cognitive impairment

The Frontal Assessment Battery (FAB) and the INECO Frontal Screening (IFS) are two instruments frequently used to explore cognitive deficits in different diseases. However, studies reporting their use in patients with mild cognitive impairment (MCI) are limited.

Demographically-adjusted norms for the Grooved Pegboard and Finger Tapping tests in Spanish-speaking adults: Results from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project

OBJECTIVE

We developed demographically-corrected norms for Spanish-speakers from the U.S.-Mexico border regions of California and Arizona on two tests of motor skills - the Grooved Pegboard Test (Pegboard) and Finger Tapping Test (Tapping) - as part of a larger normative effort.

METHOD

Participants were native Spanish-speakers from the Neuropsychological Norms for the U.S.-Mexico Border Region in Spanish (NP-NUMBRS) Project (Pegboard: N = 254; Tapping: N = 183; age: 19-60 years; education: 0-20 years; 59% women). We examined the association of demographics (age, education and gender) with raw scores. Raw test scores were then converted to demographically-corrected T-scores via fractional polynomial equations. We also examined rates of impairment (T-score < 40) based on the current norms and on previously published norms for English-speaking non-Hispanic Whites and Blacks.

RESULTS

Having more years of education was associated with better raw test score performance on both tests (p < .001), and increased age was associated with worse performance on Pegboard (p < .001). Men outperformed women on Tapping, and older age was associated with lower raw scores in men only on the Tapping non-dominant hand trial (p = .02). The normed T-scores were confirmed to be normally distributed and free from demographic influences, and resulted in expected rates of impairment. Applying existing norms for English-speaking non-Hispanic Whites and Blacks to the raw scores of Spanish-speakers generally yielded lower than expected impairment rates (2-13%), with one exception: non-dominant Pegboard, for which non-Hispanic White norms overestimated impairment (23%).

CONCLUSIONS

Present findings underscore the importance of appropriate, population-specific normative data, even for tests of motor ability.

Identifying culturally acceptable cognitive tests for use in remote northern Australia

BACKGROUND

A lack of culturally appropriate tests hampers accurate assessment of cognition in remote Australian Aboriginal communities. In Arnhem Land, this study employed a community consultation process to evaluate commonly used Western tests of executive function, memory, attention, and visuospatial function.

METHODS

An initial consultation process and a follow-up pilot study resulted in the rejection of some common tests, the development of new tests, and culturally adapted versions of others. In the subsequent 30-person main trial, adult Aboriginal volunteers were examined on nine tests, plus the Kimberly Indigenous Cognitive Assessment screen, and a brief literacy test.

RESULTS

Executive function, memory, and attention tests were found to group separately after an exploratory principal components analysis. Correlations between new tests and similar Kimberly screen items were not significant, but ceiling effects may be relevant. Six of 13 test scores were found to correlate with the literacy measure.

CONCLUSIONS

A selection of cognitive tests were identified that Aboriginal people found culturally acceptable and engaging. In particular, Self-Ordered Pointing, Trail-Making, a verbal-switching task, and a new test "Which car?" show promise for further development. This work may contribute to the need for culturally appropriate cognitive testing in Aboriginal communities.

The effect of literacy and culture on cognitive effort test performance: An examination of the Test of Memory Malingering in Colombia

Introduction: Cognitive efforts tests, such as the Test of Memory Malingering (TOMM), are widely used internationally, yet emerging research suggests that performance on the TOMM can be affected by culture and education. This study examined the specificity of the TOMM and performance differences among Colombian adults, contrasting those with varying levels of literacy in order to evaluate the impact of these variables on error rates. It was hypothesized that literacy would be positively correlated with TOMM scores. Method: The sample consisted of 256 participants: the Absolute Illiterate participants had no formal education and no ability to read or write (n = 58), Functional Illiterate participants had no formal education and only basic reading and writing skills (n = 66), Literate participants had up to 12-years of education (n = 66), and Highly Literate participants had some post-secondary education (n = 66). Group differences for Trial 1 (T1) and Trial 2 (T2) were analyzed using ANOVAs and chi-square tests, along with post-hoc comparisons. Results: Mean T2 scores for the four groups were all above the suggested cutoff score of 45: the Highly Literate group had the highest mean score (49.3, range 41 to 50), and the Absolute Illiterate group had the lowest mean score (45.5, range 30 to 50). The Absolute and Functional Illiterate groups performed significantly worse on the TOMM trials than the literate participants. Cognitive performance as measured by indicators of verbal fluency and executive control significantly correlated with TOMM performance. However, when evaluated together in hierarchical logistic regressions, only age and literacy significantly predicted TOMM scores. Conclusions: Although the performance of Colombian adults suggests that the TOMM can be used cross-culturally with literate individuals, Colombian adults with poorer literacy skills performed significantly worse, raising concerns regarding the use of this measure with educationally-diverse samples. Research and clinical implications are discussed.

The IFS (INECO Frontal Screening) and level of education: Normative data

Level of education is known to confound neuropsychological test performance. The INECO Frontal Screening (IFS) is an easy-to-use and brief measure of several domains of executive function, which has previously shown reliably clinical usefulness and superior psychometric performance when compared to other frontal screening instruments. However, previous studies with the IFS have been limited to participants with high levels of education, preventing its generalizability to populations with less than 12 years of formal education. This is crucial, as less than half of the Latin American population and a large percentage of immigrants in developed countries attain high school education. The aim of this study was to generate IFS normative data in a sample stratified by age and education levels. One hundred and sixty one healthy adults were assessed with the IFS as well as measures of global cognitive screening, namely, the Addenbrooke Cognitive Examination Revised and the Mini-Mental State Examination. Multiple lineal regression analysis showed significant effects for education and nonsignificant effects for age. A correction grid for IFS raw scores was developed and cut-off scores were calculated. The correction grid and cut-off scores may be useful in the interpretation of IFS scores in participants with low education.

Culture as a variable in neuroscience and clinical neuropsychology: A comprehensive review

Culture is a dynamic system of bidirectional influences among individuals and their environment, including psychological and biological processes, which facilitate adaptation and social interaction. One of the main challenges in clinical neuropsychology involves cognitive, behavioral and functional assessment of people with different sociocultural backgrounds. In this review essay, examining culture from a historical perspective to ethical issues in cross-cultural research, including the latest significant and publications, the authors sought to explore the main features related to cultural variables in neuropsychological practice and to debate the challenges found regarding the operational methods currently in use. Literature findings suggest a more comprehensive approach in cognitive and behavioral neuroscience, including an interface between elementary disciplines and applied neuropsychology. Thus, as a basis for discussion on this issue, the authors analyzed key-topics related to the study of new trends in sociocultural neuroscience and the application of their concepts from a clinical perspective.

Literacy versus formal schooling: influence on working memory

Previous work has demonstrated that illiterate individuals exhibit reduced performance on measures of working memory, relative to a literate cohort. Given the relationship of working memory to phonological processing, which is enhanced by literacy, we sought to examine working memory in illiterate individuals and whether differences can be attributed to artifacts of the test typically used. To the extent that differences actually exist, we also examined whether they can be attributed to the effects of literacy per se or whether they reflect the effects of formal schooling. To accomplish this, we explored the performance of four groups of participants (illiterate, functionally illiterate, self-educated literate, school-educated literate), on five tests of working memory. Illiterate groups performed more poorly than the literate groups on all measures except the "Spatial Span" forward condition and "Remembering a New Route." Our results suggest that differences in working memory performance among literate and illiterate individuals can be attributed to literacy per se. Formal schooling, however, appears to enhance working memory skills. Finally, we stress the need to use tools that are not influenced by literacy and schooling effects in the clinical assessment of illiterate individuals.

Assessing neuropsychological performance in a migrant farm working Colonia in Baja California, Mexico: a feasibility study

Neuropsychological impairments (NPI) can lead to difficulties in daily functioning and ultimately contribute to poor health outcomes. However, evidence for the feasibility of NPI assessment in resource-limited settings using tests developed in high literacy/high education cultures is sparse. The main objectives were to: (1) determine the feasibility and appropriateness of conducting neuropsychological assessments among a migrant farm worker population in Baja California, Mexico and (2) preliminary describe neuropsychological test performance in this unique population. A neuropsychological test battery was administered to 21 presumably healthy adults (8 men, 13 women) during a two-day international health services and research collaboration. All but one neuropsychological test (i.e. figure learning) was feasible and appropriate to administer to the study population. Contrary to expectations, participants performed better on verbal rather than nonverbal neuropsychological tests. Results support inclusion of neuropsychological tests into future studies among migrant farm worker populations in Baja California, Mexico.

Illiteracy and dementia

There is a current concept that illiteracy and lower educational levels are risk factors for cognitive decline and dementia. Our aims were to review the association between illiteracy and dementia; and to describe some results on neuropsychological findings in illiteracy. A literature search of the PubMed database was performed. The search terms were “dementia”, “illiteracy”, “neuropsychological evaluation”, “educational levels”, and “education”. Only papers published in Portuguese, English, and Spanish were reviewed. Illiteracy is an incontestable risk factor for dementia. It influences performance on almost cognitive tests. Many other factors could be connected to the high prevalence of dementia among illiterates: low cognitive reserve, poor control of cerebrovascular disease risk factors, difficulties in cognitive evaluation, and poor adaptation of neuropsychological tests for this specific population. Functional tests must be coupled with cognitive tests to ameliorate diagnostic accuracy.

Demographic adjustments for the Spanish version of the WAIS-III

The Spanish version of the third edition of the Wechsler Adult Intelligence Scale (WAIS-III) by TEA Ediciones is an excellent addition to available instruments for Spanish speakers. The Spanish norms function similarly to US norms for individuals aged 16-35. The norms become increasingly different for individuals 35 and older, seemingly because of the lower levels of formal education of the older Spanish cohorts. Using data from a random half of the Spanish sample, the authors developed regression equations to adjust the scaled scores for individuals with a low level of education. The adjustment is made to the level that would have been expected if the individual had 12 years of education, the median level of education of the US norms. The article includes the methodology and values necessary to make the adjustments. The scaled scores were then adjusted for individuals on the second random half of the Spanish sample and compared to the United States norms. The results showed the adjustments succeed in bringing the Spanish norms closer to the US norms.

Effects of race and socioeconomic status on the relative influence of education and literacy on cognitive functioning

Previous research has shown that reading ability is a stronger predictor of cognitive functioning than years of education, particularly for African Americans. The current study was designed to determine whether the relative influence of literacy and education on cognitive abilities varies as a function of race or socioeconomic status (SES). We examined the unique influence of education and reading scores on a range of cognitive tests in low- and higher-SES African Americans and Whites. Literacy significantly predicted scores on all but one cognitive measure in both African American groups and low-SES Whites, while education was not significantly associated with any cognitive measure. In contrast, both education and reading scores predicted performance on many cognitive measures in higher-SES Whites. These findings provide further evidence that reading ability better predicts cognitive functioning than years of education and suggest that disadvantages associated with racial minority status and low SES affect the relative influence of literacy and years of education on cognition.

Literacy affected ability to adequately discriminate among categories in multipoint Likert Scales

OBJECTIVES

To assess the effect of inability to read on a five-point Likert scale, using the WHOQOL-BREF response scale. It is hypothesized that inability to read is related to loss of discriminant power among the five-category response scale.

STUDY DESIGN AND SETTING

In a cross-sectional design, nonreaders (n=141) and subjects educated at a graduate level (n-907) were assessed. Statistical analyses combined classic and modern psychometric approaches (Confirmatory factor analysis and Rasch analysis).

RESULTS

There is a remarkable difference in the psychometric performance of items across the two subgroups. Fit indexes proved to be closer to the ideal for the graduate group, but not for the nonreader group. Reducing the number of response categories improved the model exclusively for the nonreader sample. Nonreaders do not interpret the scale as a true five-category scale, but exhibit a response pattern indicative that only three categories are in fact considered.

CONCLUSION

These results confirm the hypothesis that a multiple-category response scale is not suitable for nonreaders. They suggest that a simpler response scale should be adopted to achieve a more reliable and satisfactory psychometric performance in this population. This effect seems to be stronger when more abstract and subjective constructs are involved.

Demographically corrected norms for the Brief Visuospatial Memory Test-revised and Hopkins Verbal Learning Test-revised in monolingual Spanish speakers from the U.S.-Mexico border region

The large number of primary Spanish speakers both in the United States and the world makes it imperative that appropriate neuropsychological assessment instruments be available to serve the needs of these populations. In this article we describe the norming process for Spanish speakers from the U.S.-Mexico border region on the Brief Visuospatial Memory Test-revised and the Hopkins Verbal Learning Test-revised. We computed the rates of impairment that would be obtained by applying the original published norms for these tests to raw scores from the normative sample, and found substantial overestimates compared to expected rates. As expected, these overestimates were most salient at the lowest levels of education, given the under-representation of poorly educated subjects in the original normative samples. Results suggest that demographically corrected norms derived from healthy Spanish-speaking adults with a broad range of education, are less likely to result in diagnostic errors. At minimum, demographic corrections for the tests in question should include the influence of literacy or education, in addition to the traditional adjustments for age. Because the age range of our sample was limited, the norms presented should not be applied to elderly populations.

Cultural values underlying psychometric cognitive testing

It is proposed that culture (values, beliefs, styles of behavior) can affect neuropsychological testing. Cognitive testing represents a social situation that-as any social situation, it is one governed by implicit cultural rules. At least eight different culture-dependent values underlie cognitive testing: (1) One-to-one relationship, (2) Background authority, (3) Best performance, (4)Isolated environment (5) Special type of communication, (6) Speed, (7) Internal or subjective issues, and (8) The use of specific testing elements and strategies. In addition, it is proposed that"the distance" (e.g., gender, age, ethnicity) between the examiner and the examinee may potentially impact the testing situation. A special analysis regarding the function of instruction in cognitive tests is also presented emphasizing that test instruction interpretation is also culture-dependent. Some potential avenues of research are finally proposed.

The Stick Design test: a new measure of visuoconstructional ability

Visuoconstructional ability is an important domain for assessment in dementia. Use of graphomotor measures dominate this area; however, participants with low education produce results that cannot be easily interpreted. Our objective was to develop and validate a nongraphomotor assessment of visuoconstructional ability for use in dementia evaluations in persons with low or no education. In a longitudinal, population-based study of dementia among Yoruba residents of Ibadan, Nigeria aged 65 years and older, participants underwent clinical assessment with a battery of cognitive tests and consensus diagnosis. Performance on two visuoconstructional tests, Constructional Praxis and Stick Design, were compared. Gender, age, and education affected performance on both tests. The Stick Design test was more acceptable than Constructional Praxis as measured by the number of participants with total test failure (3.9% vs. 15.1%). The Stick Design test was significantly more sensitive to cognitive impairment and dementia than the Constructional Praxis test. We conclude that Stick Design is a reasonable test of visuoconstructional ability in older cohorts with very limited educational exposure and literacy.

Effects of culture and education on neuropsychological testing: a preliminary study with indigenous and nonindigenous population

We analyzed the influence of education and of culture on the neuropsychological profile of an indigenous and a nonindigenous population. The sample included 27 individuals divided into four groups: (a) seven illiterate Maya indigenous participants, (b) six illiterate Pame indigenous participants, (c) seven nonindigenous participants with no education, and (d) seven Maya indigenous participants with 1 to 4 years of education . A brief neuropsychological test battery developed and standardized in Mexico was individually administered. Results demonstrated differential effects for both variables. Both groups of indigenous participants (Maya and Pame) obtained higher scores in visuospatial tasks, and the level of education had significant effects on working and verbal memory. Our data suggested that culture dictates what it is important for survival and that education could be considered as a type of subculture that facilitates the development of certain skills.

Sources of errors on visuoperceptual tasks: role of education, literacy, and search strategy

The current study explored possible sources of demographic effects through analyses of errors from modified formats of the Benton Visual Retention Test (BVRT) completed by African American elders. Results indicate that: (1) reading level was a stronger predictor of BVRT performance than years of education; (2) on the single-item matching format of the task, individuals with lower reading levels disproportionately produced errors on items that differed in geometric, rather than spatial features; and (3) on a multiple-choice matching format, individuals with lower reading levels committed more errors on items where the target was located in the lower half of a 2 x 2 matrix.

Semantic and phonological processing in illiteracy

Researchers of cognitive processing in illiteracy have proposed that the acquisition of literacy modifies the functional organization of the brain. They have suggested that, while illiterate individuals have access only to innate semantic processing skills, those who have learned the correspondence between graphemes and phonemes have several mechanisms available to them through which to process oral language. We conducted 2 experiments to verify that suggestion with respect to language processing, and to elucidate further the differences between literate and illiterate individuals in the cognitive strategies used to process oral language, as well as hemispheric specialization for these processes. Our findings suggest that semantic processing strategies are qualitatively the same in literates and illiterates, despite the fact that overall performance is augmented by increased education. In contrast, explicit processing of oral information based on phonological characteristics appears to be qualitatively different between literates and illiterates: effective strategies in the processing of phonological information depend upon having had a formal education, regardless of the level of education. We also confirmed the differential abilities needed for the processing of semantic and phonological information and related them to hemisphere-specific processing.

A sociodemographic and neuropsychological characterization of an illiterate population

The objectives of this article are to characterize the performance and to discuss the performance differences between literate and illiterate participants in a well-defined study population. We describe the participant-selection procedure used to investigate this population. Three groups with similar sociocultural backgrounds living in a relatively homogeneous fishing community in southern Portugal were characterized in terms of socioeconomic and sociocultural background variables and compared on a simple neuropsychological test battery; specifically, a literate group with more than 4 years of education (n = 9), a literate group with 4 years of education (n = 26), and an illiterate group (n = 31) were included in this study. We compare and discuss our results with other similar studies on the effects of literacy and illiteracy. The results indicate that naming and identification of real objects, verbal fluency using ecologically relevant semantic criteria, verbal memory, and orientation are not affected by literacy or level of formal education. In contrast, verbal working memory assessed with digit span, verbal abstraction, long-term semantic memory, and calculation (i.e., multiplication) are significantly affected by the level of literacy. We indicate that it is possible, with proper participant-selection procedures, to exclude general cognitive impairment and to control important sociocultural factors that potentially could introduce bias when studying the specific effects of literacy and level of formal education on cognitive brain function.

Formal schooling influences two- but not three-dimensional naming skills

The modulatory influence of literacy on the cognitive system of the human brain has been indicated in behavioral, neuroanatomic, and functional neuroimaging studies. In this study we explored the functional consequences of formal education and the acquisition of an alphabetic written language on two- and three-dimensional visual naming. The results show that illiterate subjects perform significantly worse on immediate naming of two-dimensional representations of common everyday objects compared to literate subjects, both in terms of accuracy and reaction times. In contrast, there was no significant difference when the subjects named the corresponding real objects. The results suggest that formal education and learning to read and to write modulate the cognitive process involved in processing two- but not three-dimensional representations of common everyday objects. Both the results of the reaction time and the error pattern analyses can be interpreted as indicating that the major influence of literacy affects the visual system or the interaction between the visual and the language systems. We suggest that the visual system in a wide sense and/or the interface between the visual and the language system are differently formatted in literate and illiterate subjects. In other words, we hypothesize that the pattern of interactions in the functional-anatomical networks subserving visual naming, that is, the interactions within and between the visual and language processing networks, differ in literate and illiterate subjects.