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Previous studies have reported that illiterates perform more poorly than literates on a variety of neuropsychological measures. We investigated the hypothesis that putative memory deficits in illiterates are an artifact of the assessment tools used rather than a reflection of an 'underdeveloped' ability. In order to accomplish this, we designed two tests, a word list learning test and an object learning test. The illiterate group performed more poorly than semiliterate and literate groups on most variables of the word list learning test, but only on delayed recall and semantic clustering on the object learning test. Our findings suggest that poor memory performance among illiterates can be attributed both to the nature of the task, as well as to the use of different cognitive mechanisms to recall learned information. Presumably, formal education may enhance the innate ability of learning through training individuals in efficient learning and retrieval strategies. We emphasize the importance of developing and using ecologically valid neuropsychological tests to assess illiterate individuals.
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The Clinical Neuropsychologist 1385-4046/03/1702-143$16.00
2003, Vol. 17, No. 2, pp. 143–152 # Swets & Zeitlinger
Assessment of Memory Skills in Illiterates:
Strategy Differences or Test Artifact?
Vasiliki Folia and Mary H. Kosmidis
Department of Psychology, Aristotle University of Thessaloniki, Thessaloniki, Greece
Previous studies have reported that illiterates perform more poorly than literates on a variety of
neuropsychological measures. We investigated the hypothesis that putative memory deficits in illiterates are
an artifact of the assessment tools used rather than a reflection of an ‘underdeveloped’ ability. In order to
accomplish this, we designed two tests, a word list learning test and an object learning test. The illiterate
group performed more poorly than semiliterate and literate groups on most variables of the word list
learning test, but only on delayed recall and semantic clustering on the object learning test. Our findings
suggest that poor memory performance among illiterates can be attributed both to the nature of the task, as
well as to the use of different cognitive mechanisms to recall learned information. Presumably, formal
education may enhance the innate ability of learning through training individuals in efficient learning and
retrieval strategies. We emphasize the importance of developing and using ecologically valid neuro-
psychological tests to assess illiterate individuals.
Recent attention to the neuropsychological corre-
lates of illiteracy has highlighted concerns re-
garding a potential influence of educational level
on many commonly used neuropsychological
tests. Such studies have suggested that poor
performance of illiterate individuals on a variety
of neuropsychological measures may reflect the
particular cognitive processes used rather than
inherently poor cognitive abilities. Alternatively,
decreased performance relative to their literate
counterparts may reflect the nature of the tests.
Most neuropsychological tests have been de-
signed to evaluate skills that are typically devel-
oped and perfected through formal schooling
(Manly et al., 1999), thus, putting illiterates at a
disadvantage. Consequently, traditional neuro-
psychological measures may overestimate the
degree of any deficits and over-diagnose impair-
ment among the illiterate elderly (Katzman et al.,
1988; Zhang et al., 1990). For these reasons, it is
important to elucidate the cognitive mechanisms
involved in commonly assessed skills, as well as
to develop, norm, and use tests that are valid for
this subgroup of the population (Petersson, Reis,
& Ingvar, 2001).
Whereas illiterate individuals do not appear to
differ from literates in daily conversational and
memory abilities or in independent functioning,
they have been found to perform more poorly
on a variety of formal neuropsychological tests
(Ardila, Rosselli, & Rosas, 1989; Lecours et al.,
1987; Manly et al., 1999; Matute, Leal, Zarabozo,
Robles, & Cedillo, 2000; Reis, Guerreiro, &
Petersson, 2001a; Reis, Petersson, Castro-Caldas,
& Ingvar, 2001b; Rosselli, Ardila, & Rosas,
1990). A number of studies have investigated
language processing in this population (Kosmidis,
Folia, Vlahou, & Kiosseoglou, 2003; Manly et al.,
Address correspondence to: Mary H. Kosmidis, Ph.D., Department of Psychology, Aristotle University of
Thessaloniki, 54124 Thessaloniki, Greece. Tel.: þ 30-231-099-7308. Fax: þ 30-231-099-7384. E-mail: kosmidis@
Accepted for publication: May 6, 2003.
1999; Morais, Cary, Alegria, & Bertelson, 1979;
Reis & Castro-Caldas, 1997). Some have found
difculty among illiterates with explicit phono-
logical processing (Kosmidis et al., 2003; Manly
et al., 1999; Morais et al., 1979; Reis & Castro-
Caldas, 1997), which they attributed to the lack of
knowledge of the grapheme-phoneme correspon-
dence that develops through learning to read and
write. Consequently, they have suggested an over-
reliance on semantic, relative to phonological,
information in language processing (Reis &
Castro-Caldas, 1997).
Neuroimaging studies have investigated puta-
tive differences in brain activation patterns between
literate and illiterate individuals while performing a
variety of verbal tasks. It appears that when illiter-
ates process information successfully (i.e., a real-
word repetition task, verbal paired associates cued
recall task), their brain activation is similar to that of
a literate control group (Castro-Caldas, Petersson,
Reis, Askelo
f, & Ingvar, 1998a; Castro-Caldas,
Petersson, Reis, Stone-Elander, & Ingvar, 1998b;
Petersson, Reis, Askelo
f, Castro-Caldas, & Ingvar,
2000; Petersson, Reis, Castro-Caldas, & Ingvar,
1999). In contrast, on tasks on which illiterates
have difculty (i.e., pseudo-word repetition task,
poor encoding on verbal paired associates), the
differences in cognitive mechanisms used by lit-
erates and illiterates to process verbal information,
are reected in different brain activation patterns
(Castro-Caldas et al., 1998a, 1998b; Petersson
et al., 1999, 2000).
In line with ndings regarding problems with
symbolic representation of linguistic information,
several studies have investigated the nature of
visuospatial perception in illiterate individuals
(Ardila et al., 1989; Matute et al., 2000). These
studies have examined skills that are commonly
evaluated when administering paper-and-pencil
neuropsychological tests, such as copying a gure
(e.g., cube, house, Rey-Osterrieth Complex Fig-
ure), telling time, recognizing superimposed g-
ures, reading a map, drawing the plan of a room
(Ardila et al., 1989), and naming (i.e., objects,
gures, body parts; Rosselli, Ardila, & Rosas,
1990). In all cases, the performance of illiterates
was poorer than that of their literate counterparts.
Several investigators speculated that appa-
rent decits in visuoperceptual test performance
among illiterates may perhaps reect the nature of
the stimuli rather than an inherent inability to
process visual information. They speculated that
typical tests, comprising two-dimensional gures
of objects might be particularly taxing on those
who have not received training in the perception
and decoding of representational symbols. In
order to resolve this question, these investigators
compared naming of two- versus three-dimen-
sional objects in illiterates (Kremin et al., 1991;
Manly et al., 1999; Reis, Guerreiro, & Castro-
Caldas, 1994; Reis et al., 2001b; Rosselli et al.,
1990). They found improved performance on
identifying photographs of objects relative to
line drawings of them, and greater improvement
when given the actual objects. They concluded
that literacy and formal education modulate the
cognitive mechanisms involved in processing
symbolic representations of objects (Reis et al.,
1994; Rosselli et al., 1990).
Memory processes in illiteracy have also been
investigated in several studies and have yielded
conicting results. In one study, illiterates per-
formed more poorly than literates on measures of
working memory, as measured by digit span
(Morais, Kolinsky, Alegria, & Scliar-Cabral,
1998), as well as on measures of declarative
memory (i.e., word list, delayed sentence recall,
immediate and delayed short story recall), while
tests of verbal list delayed recall were unaffected
by literacy status (Manly et al., 1999). In another
study (Ardila et al., 1989), investigators found
that illiterates performed more poorly than liter-
ates on digit retention, memory curve, delayed
verbal recall, sentence repetition, immediate and
delayed logical memory, immediate recall of the
Rey-Osterrieth complex gure, immediate repro-
duction of a cube, visuospatial memory and
sequential memory, but no difference on the
immediate memory of sentences. These tasks
are all articial laboratory tasks which resemble
skills trained in school; thus, they may put illit-
erates at a disadvantage, as they may rely on
processes learned through formal education and
not represent the kinds of activities encountered
in daily life.
Such ndings raise the important clinical ques-
tion of the appropriateness of commonly used
neuropsychological tests for assessing cognitive
functioning in illiterates, given the potential for
over-diagnosing problems (Ardila et al., 1989;
Manly et al., 1999; Rosselli et al., 1990). This is
particularly important with a function such as
memory, given its preeminence in several com-
mon diagnoses in the elderly (dementia, mild
cognitive impairment, depression, etc.) the
subgroup of the population in which illiterates
are over-represented. In fact, several studies have
reported an inuence of education on the risk and
manifestation of dementia, although the mechan-
isms of this inuence remain unclear (see Castro-
Caldas & Guerreiro, 2001 for a review). Increased
education has been associated with increased
synaptic density (Katzman, 1993) and dendritic
systems (Jacobs, Schall, & Scheibel, 1993).
Consequently, it has been postulated that individ-
uals with a high level of education might have to
lose more connectivity before their dementing
process becomes manifest (brain reserve hypoth-
esis). Alternatively, these individuals might have
a greater repertoire of cognitive strategies to
compensate for their early decits. Therefore,
appropriate diagnostic tools are needed to evalu-
ate potential memory decits accurately in illit-
erate individuals.
We sought to design a memory test that would
rely on the cognitive strengths of illiterate individ-
uals rather than on those of individuals with a
formal education. In an attempt to provide a more
ecologically valid measure of verbal uency abil-
ity in illiterates, some investigators have proposed
the use of tasks that more closely resemble the
daily activities typical of illiterates. In these
studies (Petersson et al., 2001; Reis et al.,
2001a), researchers administered a verbal uency
task using the categories ‘‘animals’’ and ‘‘edible
supermarket items.’’ They found that the illiterate
group generated fewer animals than the literate
group, but an equal number of supermarket items.
They attributed this discrepancy to the abstract
nature of the former category versus the famil-
iarity of the process of generating items in the
latter category.
In the present study, we expected to conrm
previous ndings of reduced performance of illit-
erate individuals on a traditional memory task.
Our goal, however, was twofold: to establish
whether this pattern would hold true on a more
ecologically valid test, namely, a test of three-
dimensional object memory, but also to inves-
tigate potential differences in the cognitive
mechanisms used to perform successfully on the
tests. Our hypothesis was that poor performance
on a variety of neuropsychological measures
might be an artifact of the articial and unfamiliar
types of tasks usually used rather than a reection
of innately poor cognitive skills.
Fifty-four, right-handed women volunteered to partici-
pate in this study. Participants were classied according
to their literacy status. One group comprised 19
completely illiterate women [mean age ¼ 71.95 years
(SD ¼ 7.57), range: 6392 years]. These women had
never attended school due to socioeconomic reasons
(i.e., poverty in an agrarian society after World War II
and the belief at that time that, under the circumstances,
an education was not critical for girls, whereas boys
more often attended elementary school), but could sign
their initials. They lived in a small Greek town and
worked either in agriculture or as maids. In order to
control for potential sociocultural differences that
might inuence performance, we recruited another
group of 20 age-matched women [mean age ¼ 69.90
years (SD ¼ 8.91), range: 5685 years] from the same
community as the rst group, and who had attended
school from 1 to 9 years [mean education ¼ 5.35
(SD ¼ 1.90)]. The women in this group reported reading
on a regular basis, although primarily church texts and
popular magazines. Most were employed as maids. The
third group consisted of 15 more highly educated
women [mean age ¼ 61.86 years (SD ¼ 4.99), range:
5574 years]. These women had gone beyond the basic
level of education (9 years of compulsory education),
having attended school for a minimum of 10 years,
while some had a university degree as well [mean
education ¼ 13.73 (SD ¼ 2.60), range: 1016 years].
Since we could not identify such a group in the same
small town as the other two groups, we recruited these
participants from a large metropolitan area. All of the
women in this group were either currently employed or
had retired. We included only women in this study due
to the greater prevalence of illiterate women relative to
illiterate men in Greek society.
We administered two different memory tests within the
context of a more extensive neuropsychological battery.
Some of the data from the other tests have been
reported separately (Kosmidis et al., 2003).
Word List Learning Test
We administered a Greek serial verbal learning test (a
modied California Verbal Learning Test; Delis,
Kramer, Kaplan, & Ober, 1987) in which we presented
a list of 16 common words belonging to four semantic
categories (i.e., clothes, fruits, tools, spices) over ve
learning trials. Examinees repeated as many words as
they could after each trial. Learning trials were
followed by 20-min delayed free and cued recall trials.
In a nal trial, examinees were asked to recognize the
original items from among many distracter items that
either belonged to the same categories or sounded like
those in the original list, or were completely unrelated.
Object Learning Test
For the purposes of this study, we designed a learning
test similar to the word list learning test using 16 three-
dimensional objects. The objects were small enough to
all t on the table in front of the examinee and belonged
to one of four categories: toys (i.e., ball, doll, stuffed
bear, car), kitchen utensils (i.e., bowl, saucer, spoon,
can opener), medically-related objects (i.e., syringe,
latex glove, capsule, band-aid), and ofce-related
objects (i.e., pen, eraser, envelope, scissors). Examinees
rst named all of the objects to ensure familiarity with
them and their names. All objects were exposed
simultaneously for 10 s while the examinee learned
them, and were covered during recall. This process was
repeated ve times, followed by 20-min delayed free
and cued recall and a verbal recognition trial.
On both tests, variables of interest were the following:
number of words/objects recalled on the rst learning
trial, number of words/objects recalled on the fth
learning trial, number of words retrieved after 20 min
on free recall, number of words/objects retrieved on
cued recall, and number of words/objects recognized
correctly among verbally presented distracter stimuli as
belonging to the original items. We also calculated the
number of semantic clusters used during delayed free
recall (i.e., recall of two consecutive words/objects
belonging to the same semantic cluster), and percent
retention (i.e., number of words/objects learned by the
last trial which were recalled in the delayed free recall
trial). Finally, we estimated the primacy and recency
effect during the learning trials (i.e., number of words
recalled from among the rst four on the list across the
ve learning trials and number of words recalled from
among the last four on the list across the ve learning
trials, respectively). This was done only for the word
list, since the objects were presented simultaneously.
We conducted Kruskal-Wallis nonparametric tests
for three independent groups to compare the
performance of the groups on each test variable.
Given the large number of analyses, we chose to
use a ¼ 0.01 as the criterion of signicance. We
followed up signicant main effects for group
by comparing the illiterate to the semiliterate
group and the semiliterate to the literate group
with Mann-Whitney U tests. Finally, we used
Wilcoxon Signed Rank Tests for within group
comparisons. Tables 1 and 2 list the median values
for each task, by group and task variable,
Word List Learning Test
Figure 1 depicts performance on the word list
learning test by group. We found an effect of
group on the number of words recalled on the rst
(2) ¼ 12.304, p < .005. Illiterates recalled
fewer words than the semiliterate group, while
the semiliterate and literate group did not differ
from each other in the number of words recalled.
There was no group effect, however, on the
number of words recalled after ve trials,
(2) ¼ 6.974, n.s. Illiterates beneted from the
repetition and learned about the same number of
words as the two literate groups.
Group differences appeared on both delayed
recall trials. On the delayed free recall trial,
(2) ¼ 13.005, p < .001, illiterates recalled fewer
words than the semiliterate group, whereas
semiliterates and literates did not differ from each
other. The same pattern was observed on delayed
cued recall,
(2) ¼ 17.381, p < .001, where illit-
erates performed more poorly than semiliterates,
Note. Because the literate group was signicantly
younger than the other two groups, F(2, 51) ¼ 8.155,
p ¼ .001, we initially conducted multiple analyses of
variance with age as a covariate, in order to compare
performance of the groups on each test. Since we found
no age effects on any of the comparisons, we chose
to use nonparametric analyses, which excluded the
possibility of covarying for age, but were more
appropriate for behavioral data that do not meet the
assumptions of parametric tests (i.e., normal distribu-
tion). We present only the nonparametric comparisons
in this paper.
but the two literate groups did not differ from each
other. Similarly, there was a group effect on the
recognition trial,
(2) ¼ 21.580, p < .001; again,
the illiterate group performed more poorly than
semiliterate group, and the two literate groups did
not differ from each other.
Table 1. List Learning Performance (Medians) of the Three Groups.
Variable Group Group differences
Illiterate Semiliterate Literate
(paired comparisons)
1st learning trial 3.00
5.00 5.00 a
5th learning trial 10.00 14.50 14.00
Delayed free recall (DFR) 8.00
12.00 11.00 a
Delayed cued recall 12.00
14.00 13.00 a
Recognition 15.00
16.00 16.00 a
Semantic clusters (DFR) 3.00
6.00 5.00 a
Percent retention 76.92 86.61 87.50
Primacy effect 11.00 13.00 12.00
Recency effect 10.00
13.00 13.50 a
Note. Group differences were detected with Kruskal-Wallis comparisons for three independent groups. Follow-up
paired comparisons were done with Mann-Whitney U tests; those yielding signicant differences between
groups are depicted by the letter ‘‘a’’ to denote a signicant difference between illiterates and semiliterates.
The apparent discrepancy in the nding of a signicant group difference on the recognition trial in light of a
lack of difference on the 5th learning trial can be attributed to the differences in inter-quartile range for each
group on each task. On the 5th trial, the inter-quartile range for the illiterate, semiliterate, and literate groups
was 3.00, 1.88, and 2.50, respectively. On the recognition task, the inter-quartile range was 1, 0, and 0,
respectively. Skewness scores showed a major difference in the concentration of the distribution for each
group on each task, as well (5th trial: illiterates ¼0.108, semiliterates ¼1.146, and literates ¼0.512;
recognition task: illiterates ¼0.825, semiliterates ¼4.472, and literates ¼3.873).
p < .01.
p < .005.
p < .001.
Table 2. Object Learning Performance (Medians) of the Three Groups.
Variable Group Group differences
Illiterate Semiliterate Literate
(paired comparisons)
1st learning trial 9.00 9.50 10.00
5th learning trial 15.00 15.50 16.00
Delayed free recall (DFR) 12.00
14.50 14.00 a
Delayed cued recall 11.00
14.50 15.00 a
Recognition 16.00 16.00 16.00
Semantic clusters (DFR) 3.00
3.00 4.00 b, c
Percent retention 81.25 93.75 93.54
Note. Group differences were detected with Kruskal-Wallis comparisons for three independent groups. Follow-up
paired comparisons were done with Mann-Whitney U tests; those yielding signicant differences between
groups are depicted by the letters ‘‘a’’ to denote a signicant difference between illiterates and semiliterates,
‘‘b’’ a signicant difference between semiliterates and literates, and ‘‘c’’ a signicant difference between
illiterates and literates.
p < .01.
p < .005.
p < .001.
We explored potential group differences on the
strategies used to recall words upon delay. We
found a group effect,
(2) ¼ 11.554, p < .005, on
the number of semantic clusters made on delayed
free recall, wherein the illiterate group made the
fewest clusters, and the two literate groups did not
differ from each other. We found no group effect,
however, on the percentage of words retained from
the last learning trial to the delayed free recall trial,
(2) ¼ 1.358, n.s. All three groups appeared to
have retained the same percentage of words pre-
viously learned. A within group comparison of
performance on delayed free and cued recall trials
for each group separately revealed improved per-
formance on cued as compared with free retrieval;
this was true for all three groups (illiterates:
Z ¼3.269, p < .001, semiliterates: Z ¼3.538,
p < .001, and literates: Z ¼2.615, p < .01), sug-
gesting that providing semantic cues aided the
recall process.
Finally, we investigated the primacy and
recency effect in learning. Whereas the illiterates
did not differ from the other two groups with
respect to the primacy effect,
(2) ¼ 4.425, n.s.,
they showed less of a recency effect,
(2) ¼
10.016, p < .01. In other words, the illiterate partic-
ipants appeared to have emphasized rehearsal of
words heard early in the list, but not those heard
late in the list.
Object Learning Test
Figure 2 depicts performance on the object learning
test by group. Our analyses showed no group effect
on most of the variables of this test. We found no
group difference on the number of objects learned
on the rst,
(2) ¼ 1.149, n.s., and the fth trial,
(2) ¼ 1.313, n.s. We did, however, nd group
effects on delayed recall trials. More specically,
illiterates performed more poorly than the other
two groups on delayed free recall,
(2) ¼ 10.409,
p < .005; the semiliterates and literates did not
differ on this variable. On delayed cued recall we
found the same pattern,
(2) ¼ 17.468, p < .001,
wherein illiterates recalled fewer words than semi-
literates, while there was no difference between the
two literate groups. We found no group effect on
the recognition trial,
(2) ¼ 7.129, n.s., suggesting
that despite their retrieval difculties, the illiterate
participants had encoded the information.
We conducted several analyses to explore the
strategies used in the delayed recall of test items.
With respect to semantic clustering, we found a
group effect,
(2) ¼ 9.864, p < .01: the illiterate
and semiliterate groups did not differ from each
other, but both made fewer clusters than the literate
group. There was no group effect on the percentage
of objects retained from the nal learning trial to
the delayed free recall trial,
(2) ¼ 5.388, n.s.
When we compared performance on delayed free
and cued recall for each group separately, we found
the following results: free and cued recall differed
neither for the illiterate (Z ¼.191, n.s.) nor for
the semiliterate (Z ¼2.060, n.s.) group, whereas
for the literate group (Z ¼2.636, p ¼ .01) word
retrieval improved on the cued, relative to the free,
recall trial.
Fig. 1. Median number of words recalled on the word
list learning test for each group.
Note. DFR ¼ delayed free recall; DCR ¼
delayed cued recall; REC ¼ recognition.
Fig. 2. Median number of words recalled on the object
learning test for each group.
Note. DFR ¼ delayed free recall; DCR ¼
delayed cued recall; REC ¼ recognition.
We investigated the hypothesis that the poor per-
formance of illiterate individuals on neuropsycho-
logical tests often reported in the literature is an
artifact of the types of tests used rather than an
indication of decient cognitive skills. We were
also interested in whether illiterates used different
strategies to perform the tests as compared with
their semiliterate and literate counterparts. Our
results both replicate and extend previous ndings.
The illiterate participants in the present study
performed more poorly than semiliterates on most
word list learning test variables, while the two
literate groups generally did not differ from each
other. More specically, the illiterate group per-
formed more poorly than the other two groups on
rst trial and delayed recall, recognition, and
semantic clustering. With repetition, however, they
were able to match the number of words learned by
the other groups by the last learning trial, and to
retain the same percentage of these words upon
delayed recall, as the literate groups. In contrast, on
an object learning test, the illiterate group showed,
from the onset, the same initial recall, learning
ability, retention rate, and recognition rate as the
two literate groups, but did not use semantic
clustering strategies or recall as many words after a
20-min delay as the other groups.
The pattern of performance of our groups
suggested reduced facility on initial presentation,
with improvement only after repetition on learn-
ing trials of verbally presented material among
illiterate individuals, but no evident difculty on
learning visually presented objects. This discre-
pancy could be attributed to the fact that remem-
bering objects in ones environment is more
typical of daily activities, and does not require
the abstract strategies necessary to remember a
word list. Therefore, it would appear that the
former test might put illiterates at a disadvantage,
whereas the latter test may be a more ecologically
valid measure of learning and memory abilities
for this subgroup of the population. We must
emphasize, however, that illiterates had difculty
on long-term recall on both tests, suggesting a
semantic retrieval problem.
Since our interest was in examining memory
strategies in illiterate individuals, in addition to
their overall performance, we designed tests that
were not rote memory tasks, but that relied on
concept formation abilities. Both tests comprised
items that belonged to conceptual categories,
which, presumably, would assist retrieval through
semantic associations. This type of test could
potentially provide important information about
the use of effective learning strategies, as well as
concept formation skills (Lezak, 1995). Interest-
ingly, the illiterate group did not actively benet
from the conceptual information inherent in the
item lists by recalling words according to semant-
ic clusters. All three groups, however, improved
their recall of the word list when given the
semantic categories as cues. This was not true
on the object test, where only the literate group
beneted from the cues on delayed recall relative
to free recall.
With respect to primacy and recency effects,
we evaluated these only on the word list learning
test, in which items were presented serially. The
illiterate group differed from the other groups
only on the recency, and not the primacy effect.
This may reect an emphasis on rehearsal of the
rst few words (primacy effect), but a neglect of
rehearsal of the most recently presented words on
the list.
The fact that the illiterate participants did well
on the object test raises the question that perhaps
they were aided by the spatial information inher-
ent in the object test since objects were placed in a
specic place in front of the examinees. Exam-
ination of the physical proximity of objects to
each other and the order of recall, however, failed
to support the hypothesis that they used a strategy
of spatially clustering the objects recalled. It is also
possible that the object test was easier than the word
list test for all groups, since there appeared to be a
ceiling effect for the other groups. In fact, at least
one study has reported ndings that suggest that
spatial memory may be an automatic process
(Andrade & Meudell, 1993). While at times mem-
bers of all three groups pointed to the spatial
location of an object in trying to recall it, in these
cases, they failed to recall the name of the particular
object. Thus, spatial information did not appear to
aid recall substantially.
On the surface, one might conclude that the
decreased performance of the illiterate group on the
word list test is an indication of poor memory skills.
In fact, the combination of poor recall and poor
recognition of word lists has been documented in
patients with temporal lobe damage and amnesia
(Jetter, Poser, Freeman, & Markowitsch, 1986),
thus, reecting a memory problem. While memory
skills are innate in healthy individuals such as those
who participated in the present study, it is certainly
conceivable that they could be augmented signi-
cantly through training such as that received during
formal education. Therefore, the specicpattern
observed in the present study may reect less or
differently developed encoding skills among illit-
erates as compared with literates.
In contrast to the aforementioned pattern of
overall poor performance on verbal list learning,
the pattern observed on the object test revealed
specic areas of difculty. Poor free recall of
items in light of good recognition has been
found in studies of patients with frontal lobe
damage (Janowsky, Shimamura, Kritchevsky, &
Squire, 1989). In our healthy groups, this pattern
among the illiterate participants on the object
learning test might reect inefcient encoding
and retrieval strategies or impaired organization
of the material to be learned, leading to relatively
poorer recall (Eslinger & Grattan, 1992). Recall
of learned information generally occurs without
cues or external support, and, thus, necessitates
considerable self-initiated activity (Craik &
Jennings, 1992). Consequently, the process of
recalling information appears to be heavily
dependent on executive skills rather than merely
on memory abilities (see Parkin & Leng, 1993). In
our illiterate group, these skills may have been
adequate for a relatively passive cognitive process
such as efcient recognition of stimuli learned
through repetition, yet inadequate to support a
relatively active and effortful cognitive process
such as free recall (Spreen & Strauss, 1998).
At least one study supports the above conten-
tion. Investigators found an improvement in cog-
nitive functions, including verbal memory, not
specically targeted in an adult learning-to-read
program. They concluded that learning to read
enhanced metacognitive principles such as using
analytic strategies, planning, organizing output
sequences, etc., which are related to executive
functions (Ardila, Ostrosky-Solis, & Mendoza,
2000). Whether this improvement is a direct result
of literacy acquisition or a reection of the values
instilled in those who undergo formal training
(i.e., school) is not clear, but it is a question
worthy of more extensive investigation.
A signicant limitation of the present study is
the method of presentation of the items on the
object test. In order to use actual objects, we
chose to present the items simultaneously. A
future study could examine the serial presentation
of either objects or photographs of objects in
order to provide a test that is more similar to the
word list learning test. This would enable a direct
comparison of performance on the two tests.
Another limitation is that the two tasks differed
only in their encoding requirements (language-
based vs. visual cues), whereas they both
depended on similar retrieval processes (lan-
guage-based cues). The use of language-based
cues on the object test may account for the
difculties encountered by the illiterates in object
recall. Future investigations should use visual
attributes as cues. Finally, the order of test admin-
istration was the same for all participants,
whereby the verbal task was presented before
the object test within a longer battery of tests.
Therefore, it is possible that the improved perfor-
mance of the illiterates on the object test was due
to the effect of practice, whereas the literate
groups had already performed well to begin with.
Some characteristics of our sample may limit
the generalizability of our ndings. We studied
only right-handed illiterate women because they
were easiest to nd. Therefore, the current nd-
ings may not be generalizable to illiterate men or
to left-handed individuals. Other investigations of
illiteracy have also depended on the study of
women for the same reason, namely, availability
(Petersson et al., 2000, 2001; Reis & Castro-
Caldas, 1997; Reis et al., 1994, 2001a, 2001b).
To our knowledge, investigations including illit-
erate men and women have not explored gender
effects on any cognitive measures (Manly et al.,
1999; Ratcliff et al., 1998).
The fact that we used unstandardized measures
of memory in the present study may appear to
limit their use as diagnostic tools. Our goal in
undertaking the present study, however, was not
necessarily to establish new tests for diagnosing
memory problems. Instead, through observing
their performance on two different memory
tests, we sought to explore potential differences
in the cognitive strategies used by illiterate and
literate individuals to perform successfully. In this
way, we hoped to propose the characteristics a
memory test should have in order for it to be more
appropriate than traditional tests for use with
Our ndings suggest that poor memory perfor-
mance among illiterates can be attributed both to
the nature of the task, as well as to the use of
different retrieval mechanisms. Such innate learn-
ing mechanisms might be enhanced by training
individuals in efcient learning and retrieval stra-
tegies. It is important to develop and use ecolo-
gically valid neuropsychological tests to assess
illiterate individuals. The present study is a step in
this direction.
This work was supported by a European Commission
Grant (5th Framework Program QLK6-CT1999-2140)
to M.H.K. It was presented at the 17th Meeting of the
Hellenic Society for Neuroscience, Rethymno, Crete,
October 46, 2002. We would like to thank Christina H.
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... [8][9][10] With respect to memory, they present worse performance in learning and remembering word lists, 11,12 association of paired words, 11,13 and memory for stories and digits. 11 In tests that evaluate memory for objects 12,14 and word list recognition 14 the performance of illiterate elderly is similar to literates. ...
... [8][9][10] With respect to memory, they present worse performance in learning and remembering word lists, 11,12 association of paired words, 11,13 and memory for stories and digits. 11 In tests that evaluate memory for objects 12,14 and word list recognition 14 the performance of illiterate elderly is similar to literates. ...
Introduction: The accuracy of commonly used screening tests for Alzheimer's disease (AD) has not been directly compared to those that could be more appropriate for lower schooling. Objective: To compare the diagnostic accuracy of usual screening tests for AD with instruments that might be more appropriate for lower schooling among older adults with low or no literacy. Methods: The study included a clinical sample of 117 elderly outpatients from a Geriatric Clinic classified as literate controls (n = 39), illiterate controls (n = 30), literate AD (n = 30) and illiterate AD (n = 18). The tests were compared as follows: Black and White versus Colored Figure Memory Test; Clock Drawing Test versus Clock Reading Test; Verbal Fluency (VF) animal versus grocery category; CERAD Constructional Praxis versus Stick Design Test. Results: The means of literate and illiterate controls did not differ in the Black and White Figure Memory Test (immediate recall), Colored Figure Memory Test (delayed recall), Clock Reading Test and VF animals and grocery categories. The means of the clinical groups (controls versus AD), in the 2 schooling levels, differed significantly in most of the tests, except for the CERAD Constructive Praxis and the Stick Design Test. Diagnostic accuracy was not significantly different between the compared tests. Conclusion: Commonly used screening tests for AD were as accurate as those expected to overcome the education bias in a sample of older adults with lower or no education.
... This is important for a better understanding of the pain concepts. Furthermore, previous studies have reported that non-literates perform poorly in interventions requiring educational sessions [52]. However, frequent repetitions of the concepts have been found to improve memory among non-literates [53]. ...
Purpose To pilot feasibility and assess preliminary effectiveness of standard and culture-sensitive Pain Neuroscience Education (PNE) among Hausa-speaking patients with Chronic Neck Pain (CNP). Methods Adverts (online & clinic-based) were used to recruit Hausa-speaking patients with nonspecific CNP in Kano, Nigeria. Selected participants were randomized to culture-sensitive PNE (CSPNE), standard PNE (PNE), or control groups. Each group received bi-weekly sessions of exercise therapy for 6 weeks. Two sessions of PNE plus a home-based session were administered before exercise therapy in the PNE groups. Primary (pain-intensity and disability) and secondary (pain-knowledge, pain catastrophizing, and quality of life) outcomes were measured. The study was pre-registered (PACTR201902788269426). Results Fifty-three (out of 64) participants met the inclusion criteria. The majority of them were recruited through radio adverts (83%). Interventions were successfully administered and data collection was completed for the participants. About 15% and 17% drop-out rate was recorded before intervention (post-randomization) and during follow-up, respectively. Main results indicated that significant within-group improvements in disability and pain knowledge scores were found in favor of the PNE groups. Conclusion Culture-sensitive and standard PNE plus exercise therapy are feasible for Hausa patients with CNP, and current findings indicate support for reducing disability and increasing pain knowledge among them. • Implications for rehabilitation • Both standard PNE and culture-sensitive PNE are feasible for administration as interventions for Hausa-speaking patients with CNP. • Radio adverts may be necessary for patients recruitment in addition to specialists’ referrals. • Culturally sensitive PNE materials may be more desirable as an intervention option due to the low literacy level among the Hausa population.
... Many investigations of the neuropsychological correlates of illiteracy and/or lack of schooling have focused on performance differences between uneducated/illiterate and educated/literate individuals, documenting poorer performance among the former compared to the latter. Indeed, healthy uneducated/illiterate individuals tend to underperform on tests of language (Kosmidis, Tsapkini, & Folia, 2006;Reis & Castro-Caldas, 1997), with the exception of supermarket fluency (Reis, Guerreiro, & Petersson, 2003) and verbal recognition (da Silva, Petersson, Faisca, Ingvar, & Reis, 2004;Youn et al., 2011); visuospatial perception (Brucki & Nitrini, 2008;Byrd, Jacobs, Hilton, Stern, & Manly, 2005;Hong et al., 2011), with the exception of the Remembering-a-New-Route task (Kosmidis, Zafiri, & Politimou, 2011) and object learning (Chung, 2009;Folia & Kosmidis, 2003); memory and learning (Ardila, Rosselli, & Rosas, 1989;Manly et al., 1999;Nitrini et al., 2004); attention (van Linden & Cremers, 2008); working memory (Kosmidis et al., 2011); and executive functioning (Gómez, Zunzunegui, Lord, Alvarado, & García, 2013). The format of these tests resembles that of tasks typically used in school. ...
Objectives We investigated the utility of traditional neuropsychological tests in older uneducated/illiterate individuals without dementia to determine the possibility that they are likely not appropriate for this group. Methods We assessed the neuropsychological performance of 1122 older adults [≥65 years old; mean age: 74.03 ( SD = 5.46); mean education: 4.76 ( SD = 2.5) years; women: n = 714], in the context of the Hellenic Longitudinal Investigation of Aging and Diet (HELIAD), a population-based study conducted in Greece. Results We based our analyses on three groups: high-functioning/cognitively healthy (i.e., without dementia) uneducated/illiterate individuals ( n = 80), high-functioning/cognitively healthy educated/literate individuals ( n = 932), and low-functioning/cognitively impaired educated/literate individuals (presumably with dementia; n = 110). We used binary regression analyses with Bonferroni correction to investigate whether test performance differentiated uneducated/illiterate from educated/literate individuals. Models were adjusted for age and sex; raw test scores were the predictor variables. The uneducated/illiterate cohort was at a disadvantage relative to the healthy educated/literate group on all variables but verbal memory recognition and consolidation, congruent motor responses, and phonological fluency clustering ( p > .002). Moreover, only word list learning immediate and delayed free recall and delayed cued recall differentiated the high-functioning/cognitively healthy uneducated/illiterate from the low-functioning/cognitively impaired educated/literate group, favoring the former ( p’s < .002). Conclusions Our findings suggest that only particular verbal memory test variables are fair in determining whether older uneducated/illiterate individuals have functional/cognitive impairment suggestive of a neurodegenerative process. On all other neuropsychological variables, this cohort was at a disadvantage. Therefore, we highlight the need for identifying appropriate methods of assessment for older uneducated/illiterate individuals.
... (V. P. Bozikas et al., 2003;Folia & Kosmidis, 2003;Kosmidis, Bozikas, Zafiri, & Karavatos, 2006;Liozidou, Potagas, Papageorgiou, & Zalonis, 2012;Messinis, Kyprianidou, Malefaki, & Papathanasopoulos, 2006;Zalonis et al., 2010). The translations of neuropsychological textbooks, the development and the standardization of tests, as well as the production of Greek norms for widely used neuropsychological instruments, has been, and remains, a key research topic for these research laboratories (V. ...
Neuropsychology is a fast-growing specialty in Greece. This study surveyed the status of neuropsychologists in Greece investigating several aspects of the profession. An online-based questionnaire collected data from December 2019 to February 2020. A total of 133 participants specialized in neuropsychology were included in the final sample: 81% of the participants were women with a mean age of 35 years. In the total sample, 25.8% of the participants reported working in the hospital system, 18.5% in the university or college, and 17.7% in a private practice job. Greek professionals cited to engage actively in assessment (87.9%), in research (65.1%), in rehabilitation (47.7%), and teaching (30.2%). Professionals primarily declared to assess individuals with dementia (80.3%), depression (47.7%), and stroke (44.0%), and they reported neurologists, psychiatrists and psychologists as their leading sources of referrals. The top five perceived barriers to the field include the lack of recognized specialty (75.9%), the lack of clinical training opportunities (63.9%), the lack of strong professional associations (57.9%), the lack of access to neuropsychological instruments (57.9%) and the lack of willingness to collaborate between professionals (48.9%). The average monthly income of professionals represents a ratio of 0.76 in comparison to that of other scientists in the country and is the lowest reported among other countries. Despite the significant development of the profession, it is essential to create more clinical training opportunities, apply practices systematically to diverse populations, redefine the specialty of neuropsychology in the national health system of the country, and advocate for the profession.
... The expert group also recommended the development of ICMR-NCTB for illiterates/low-literacy groups. This was based on research that suggested that illiterates differ in the use of cognitive strategies involved in memory, phonological processing, visuospatial, and other domains, which impacts their performance on tasks developed in predominantly literate settings (Castro-Caldas, Petersson, Reis, Stone-Elander, & Ingvar, 1998;Folia & Kosmidis, 2003). Review of existing batteries suggested that apart from the Hindi cognitive test battery, majority of tests were applicable for use mainly in educated subjects. ...
Recently there have been ongoing efforts to harmonise research across dementia cohorts from different centres and countries. Establishing comparability of cognitive test performance across languages and educational levels therefore becomes crucial. Differences due to educational disparity or linguistic variability will need to be differentiated from more genuine differences due to disease. This is especially important in countries like India that are characterised by a socioculturally heterogeneous population. To address this, the Indian Council of Medical Research‐Neuro Cognitive Test Battery (ICMR‐NCTB) was developed and validated to diagnose dementia in five Indian languages. In this study, we aimed to investigate the cognitive construct and comparability of the ICMR‐NCTB across five Indian languages using confirmatory factor analysis and measurement invariance. 991 healthy literate controls with normal cognition (Telugu = 302; Hindi = 191, Malayalam = 195; Bengali = 135 and Kannada = 168) were assessed with the ICMR NCTB which includes tests of attention/executive function, verbal and visual episodic memory, language and visuospatial Functions. The dimensional structure of ICMR‐NCTB was studied with regard to its cognitive constructs, and measurement invariance across five different Indian languages was evaluated. Confirmatory factor analysis of the data demonstrated that a five factor model in which the tests were divided into the cognitive domains: attention/executive function, verbal memory, non‐verbal memory, language and visuospatial functions provided the best model fit both within and across all five languages. Analysis of factorial invariance across groups indicated that configural and metric invariance were achieved, thereby suggesting that the tests of the ICMR‐NCTB measure the same cognitive construct across different languages. On analyzing scalar invariance, non‐invariance of intercept was demonstrated, indicating a possible measurement bias between the different language groups. The study results indicate that cognitive constructs measured by the tests in the ICMR‐NCTB across the five different Indian languages are the same. However, there are differences that influence the performance of subjects across languages groups. The study findings have significant implications for harmonising cognitive test data in dementia research that involves linguistically diverse cohorts.
... 82 Most instructive are the findings that show a limited capacity amongst present-day illiterates for deriving meaning from the written word. Even allowing for differences in memory recall 83 between literates and non-literates, 84 it is noted that 'illiterates can develop some ability to holistically recognize a few highly frequent words, such as the name of their country, and the name of some popular commercial products'. 85 Skills extend further to the ability to recognize letters, to write one's name with no knowledge of its phonology, and most notably, to correctly identify many logographic signs. ...
Departing from the traditional approaches taken toward ancient Egyptian potmark interpretation, this paper draws on modern conventions of commodity branding to show how internally placed textual markings on bread moulds functioned as brands for marking the surfaces of select loaves at Tell Gabbara during the late Second Dynasty. Specific properties of three potmarks are examined with the aims of elucidating their brand characteristics and showing how they might have functioned in diverse capacities simultaneously, serving not only as linguistically based messages, but also as logos. Furthermore, the ability of bread brands to convey a unified message to members of a blended literate and non-literate workforce is assessed briefly through multidisciplinary findings from fields such as marketing, psycholinguistics, and clinical neuropsychology. The author suggests that these disciplines have the potential to inform and transform our perceptions of the cognitive capabilities of illiterate people with regard to negotiating the messages inherent in early Egyptian brand markings.
... However, this study did not test phonological processing specifically. A separate but related issue relates to the open question of whether literacy only affects performance on tasks that require conscious manipulation of speech sounds and units (such as phoneme deletion and phonological fluency), or whether it also affects more implicit phonological processing involved in everyday language processing and learning, as discussed, for instance, by [50] and [51]. We return to this when discussing [52] below. ...
Full-text available
Language input in childhood and literacy (and/or schooling) have been described as two key experiences impacting phonological processing. In this study, we assess phonological processing via a non-word repetition (NWR) group game, in adults and children living in two villages of an ethnic group where infants are rarely spoken to, and where literacy is variable. We found lower NWR scores than in previous work for both children (N = 17; aged 1-12 years) and adults (N = 13; aged 18-60 years), which is consistent with the hypothesis that there would be long-term effects on phonological processing of experiencing low levels of directed input in infancy. Additionally, we found some evidence that literacy and/or schooling increases NWR scores, although results should be interpreted with caution given the small sample size. These findings invite further investigations in similar communities, as current results are most compatible with phonological processing being influenced by aspects of language experience that vary greatly between and within populations.
... Learning to read and write affects both memory strategies (Laboratory of Comparative Human Cognition 1983) and several kinds of memory: verbal, visual, working memory, and phonological STM skills (Conti-Ramsden and Durkin 2007; for review, see Ardila et al. 2010). However, literacy does not seem to affect all types of memory, as neither object memory (e.g., Folia and Kosmidis 2003) nor wordlist recognition memory was found to be related to literacy level (Ardila et al. 1989). ...
Full-text available
The different environmental conditions in which people live might challenge memory in different ways. Moreover, the frequency of usage can be a source of improvement of both short- and long-term memory. The aim of our study was to investigate the effects of environmental differences on short- and long-term memory in a traditional versus a contemporary population (Dani of Papua, n = 62; Polish, n = 134). We found that both short- and long-term memory varied in the two populations, living in totally distinct surroundings. However, there were no age differences between Polish and Dani participants in either short- or long-term memory tasks, indicating that culture was not a significant moderator of the memory differences between populations. The differences in short- and long-term memory between the two populations are consistent with the argument that short-term memory plays a more significant role in contemporary societies because of technical developments, the electronic revolution, and reading ability. The lack of an age difference appears to support the assumption that it is age, not culture, that plays a crucial role in the memory performance.
... The expert group also recommended the development of ICMR-NCTB for illiterates/low-literacy groups. This was based on research that suggested that illiterates differ in the use of cognitive strategies involved in memory, phonological processing, visuospatial, and other domains, which impacts their performance on tasks developed in predominantly literate settings (Castro-Caldas, Petersson, Reis, Stone-Elander, & Ingvar, 1998;Folia & Kosmidis, 2003). Review of existing batteries suggested that apart from the Hindi cognitive test battery, majority of tests were applicable for use mainly in educated subjects. ...
Full-text available
Objectives: While the burden of dementia is increasing in low- and middle-income countries, there is a low rate of diagnosis and paucity of research in these regions. A major challenge to study dementia is the limited availability of standardised diagnostic tools for use in populations with linguistic and educational diversity. The objectives of the study were to develop a standardised and comprehensive neurocognitive test battery to diagnose dementia and mild cognitive impairment (MCI) due to varied etiologies, across different languages and educational levels in India, to facilitate research efforts in diverse settings. Methods: A multidisciplinary expert group formed by Indian Council of Medical Research (ICMR) collaborated towards adapting and validating a neurocognitive test battery, that is, the ICMR Neurocognitive Tool Box (ICMR-NCTB) in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam), for illiterates and literates, to standardise diagnosis of dementia and MCI in India. Results: Following a review of existing international and national efforts at standardising dementia diagnosis, the ICMR-NCTB was developed and adapted to the Indian setting of sociolinguistic diversity. The battery consisted of tests of cognition, behaviour, and functional activities. A uniform protocol for diagnosis of normal cognition, MCI, and dementia due to neurodegenerative diseases and stroke was followed in six centres. A systematic plan for validating the ICMR-NCTB and establishing cut-off values in a diverse multicentric cohort was developed. Conclusions: A key outcome was the development of a comprehensive diagnostic tool for diagnosis of dementia and MCI due to varied etiologies, in the diverse socio-demographic setting of India.
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Nesta contribuição examinamos as conseqüências da aquisição de um sistema alfabético de representação da linguagem sonre as estruturas psicológicas. Em primeiro lugar, descrevemos os dados empíricos que demonstram que a literacia alfabética suscita a emergência da consciência fonémica. Muitos destes estudos foram realizados em populações de iletrados de Portugal, Espanha e Brasil. Distinguimos entre a sensibilidade fonológica, a consciência fonológica e a consciência fonémica. Em seguida, apresentamos as conseqüências da consciência fonémica sobre a maneira como as pessoas conceptualizam a fonologia de sua língua e fazem atenção a ela. Por fim, mostramos que a literacia alfabética influencia os estádios tardios do reconhecimento das palavras faladas mas não os processos mais precoces, entre os quais em especial a extração automática da informação fonética
Originally published in 1993, this book provides the clinician, researcher and student with a comprehensive account of the neuropsychology of the amnesic syndrome. The opening chapter places the amnesic syndrome within the overall context of memory disorders and provides a theoretical basis for understanding the presentation of the clinical and experimental findings which form the major part of the work. The second chapter provides an extensive account of the various methods used to assess memory and associated deficits and provides guidelines as to the most effective assessment strategy. The next five chapters are concerned with the specific aetiologies giving rise to the amnesic syndrome: Wernicke-Korsakoff Syndrome; Thalamic Amnesia; Medial Temporal Lobe Amnesia; Herpes Simplex Encephalitis; and ruptured aneurysms of the anterior communicating artery. Each of these chapters contains an account of the associated neuropathology, descriptions of experimental findings and illustrative case histories from the authors’ own experimental and clinical experience. The next chapter provides the reader with an account of some of the more important scientific issues that have arisen from the studies of the amnesic syndrome and a final chapter considers current and future prospects for behavioural remediation of severe memory deficit.
In clinical researsch one is constantly confronted with the question of normality since pathological behaviour can only be defined with regard to data establishing normal functioning. Confrontation naming is one of the most commonly explored performances in neuropsychological examination and in assessing aphasia. The task of picture naming is not only part of the initial assessment of pathologcal deficits but is also used to evaluate longitudinal changes in pathologcal performance related to treatment effects or to the spontaneous COUI-se of the disease.
[reviews] research on adult age differences in human memory . . . conducted very largely within the framework of current theoretical views of memory / organized in terms of the topics and concepts suggested by these approaches / the literature on memory and aging is now so extensive that the review must be selective—we [the authors] focus on topics of current debate and largely on research reported in the last 10 years approaches to the study of memory [memory stores, processing models, memory systems] / empirical evidence [sensory and perceptual memory, short-term and working memory, age differences in working memory] / age differences in encoding [qualitative differences in encoding] / age differences in retrieval / age differences in nonverbal memory / age differences in memory of the past and for the future / aging and memory systems (PsycINFO Database Record (c) 2012 APA, all rights reserved)