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Communication problems are not limited to patients with limited English proficiency. Even among those whose native language is English, communication can be complicated by differences in literacy.

It has been estimated that 21-23% of adults, or 40 to 44 million Americans, are functionally illiterate. They are unable to use reading, speaking, writing and computation skills in everyday life situations. With reading abilities at about the 4th grade level, they are unable to fill out an employment application, follow written instructions or read a newspaper. An additional 25% -28% of adults, another 50 million, have only marginal literacy skills, meaning they cannot understand, interpret and apply written material to accomplish daily tasks. They read at about the 8th grade level but cannot, for example, comprehend a newspaper or digest magazine. The greatest number of low-literate adults are native-born whites, but the elderly, nonwhites, immigrants and the poor are disproportionately low-skilled. (National Adult Literary Survey, U.S. Department of Education, 1993)