What term describes the ability to obtain read understand and act on health information?

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. AHRQ-funded researchers have developed four tools to measure an aspect of health literacy—individuals' reading comprehension in a medical context. This page includes two new tools that allow direct comparison of health literacy in speakers of English and Spanish. These tools can be used for research, clinical, or program planning purposes.

For additional measures of individuals' health literacy, go to the Health Literacy Tool Shed, funded by the U.S. National Libraries of Medicine.

Health Literacy and How to Assess It

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. AHRQ-funded researchers have developed a variety of tools to measure an aspect of health literacy—individuals' reading comprehension in a medical context.

The AHRQ-supported tools are for the assessment of health literacy in speakers of English and Spanish, the languages most frequently spoken in the United States.

These tools can be used for research, training, or program planning purposes as long as credit is given to AHRQ as the source. (Users of the tools who publish their findings can find a link listed with each tool to the paper that describes its initial development and validation.) The tools available from AHRQ are the:

• Short Assessment of Health Literacy–Spanish and English
• Rapid Estimate of Adult Literacy in Medicine–Short Form
• Short Assessment of Health Literacy for Spanish Adults

Note: Direct translation of these tools into another language may not produce a valid assessment of health literacy in the new language. Please contact AHRQ's Office of Communications and Knowledge Transfer for permission and to be put in contact with a technical expert before attempting a translation.

Short Assessment of Health Literacy–Spanish and English (SAHL-S&E)

The Short Assessment of Health Literacy–Spanish and English (SAHL–S&E) is a new instrument, consisting of comparable tests in English and Spanish, with good reliability and validity in both languages. Persons being examined in English or Spanish are presented with 18 test terms. For each term a key word with a related meaning and a distractor word unrelated in meaning to the test term. This tests the subject’s comprehension as well as pronunciation (decoding) of health-related terms. Administration of the test takes only 2-3 minutes and requires minimal training. Administration of these instruments could be facilitated by using laminated 4”-by-5” flash cards, with each card containing a medical test term printed in boldface on the top and the two association words—i.e., the key and the distracter—at the bottom.

SAHL–S&E validation study:
Lee S.-Y. D., Stucky B.D., Lee J. Y. et al. Short assessment of health literacy–Spanish and English: A comparable test of health literacy for Spanish and English speakers HSR 2010 August;45(4):1105–20. Pub Med ID (PMID): 20500222 [Full text available in PubMedCentral]

Contents:

SAHL-S Test Form & User’s Guide (Select for PDF [36.33 KB])
SAHL-E Test Form & User’s Guide (Select for PDF [53.04 KB])

SAHL-S Test Form

The 18 items of SAHL-S, rank-ordered according to difficulty (keys and distracters are listed in the same random order as in the field interview)

The answers can be found by selecting the SAHL-S Answer Key.

Instruction for Administering SAHL-S

Here are directions for using SAHL-S with flash cards, as described earlier. The subjects should not be shown the whole list at one time.

Directions to the Interviewer:

Before the test, the interviewer should say to the examinee:

”Le voy a mostrar tarjetas con 3 palabras en ellas. Primero, me gustaría que usted lea la palabra arriba en voz alta. Entonces, yo leeré las dos palabras debajo a usted y me gustaría que usted me dijera cuál de las dos palabras es más similar a la palabra arriba. Si usted no sabe la respuesta, por favor diga, ‘No sé’. No adivine.”

Show the examinee the first card.

The interviewer should say to the examinee:

“Ahora, por favor, lea la palabra arriba en voz alta.”

The interviewer should have a clipboard with a score sheet to record the examinee’s answers. The clipboard should be held such that the examinee cannot see or be distracted by the scoring procedure.The interviewer will then read the key and distracter (the two words at the bottom of the card) and then say:

“Cuál de las dos palabras es más similar a la palabra arriba? Si usted no sabe la respuesta, por favor diga, ‘No sé’.

The interviewer may repeat the instructions so that the examinee feels comfortable with the procedure.

Continue the test with the rest of the cards.

A correct answer for each test item is determined by both correct pronunciation and accurate association. Each correct answer gets one point. Once the test is completed, the interviewer should tally the total points to generate the SAHL-S score.

A score between 0 and 14 suggests the examinee has inadequate health literacy.

SAHL-E Word Sets & User's Guide

The 18 items of SAHL-S, rank-ordered according to item difficulty (keys and distracters are listed in the same random order as in the field interview).

The answers can be found by selecting the SAHL-E Answer Key.

Instructions for Administering SAHL-E

Here are directions for using SAHL-E with flash cards, as described earlier. The subjects should not be shown the whole list at one time.

Directions to the Interviewer:

Before the test, the interviewer should say to the examinee:

“I’m going to show you cards with 3 words on them. First, I’d like you to read the top word out loud. Next, I’ll read the two words underneath and I’d like you to tell me which of the two words is more similar to or has a closer association with the top word. If you don’t know, please say ‘I don’t know’. Don’t guess.”

Show the examinee the first card.

The interviewer should say to the examinee:

“Now, please, read the top word out loud.”

The interviewer should have a clipboard with a score sheet to record the examinee’s answers. The clipboard should be held such that the examinee cannot see or be distracted by the scoring procedure.

The interviewer will then read the key and distracter (the two words at the bottom of the card) and then say:

“Which of the two words is most similar to the top word? If you don’t know the answer, please say ‘I don’t know’.”

The interviewer may repeat the instructions so that the examinee feels comfortable with the procedure.

Continue the test with the rest of the cards.

A correct answer for each test item is determined by both correct pronunciation and accurate association. Each correct answer gets one point. Once the test is completed, the interviewer should tally the total points to generate the SAHL-E score.

A score between 0 and 14 suggests the examinee has low health literacy.

Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF)

The Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF) is a 7-item word recognition test to provide clinicians with a valid quick assessment of patient health literacy. The REALM-SF has been validated and field tested in diverse research setting, and has excellent agreement with the 66-item REALM instrument in terms of grade-level assignments.

REALM-SF Validation study: Arozullah AM, Yarnold PR, Bennett CL, et al. Development and validation of a short-form, rapid estimate of adult literacy in medicine. Med Care 2007 November;45(11):1026–33. PMID: 18049342

Note: The REALM-SF was developed with AHRQ funding, independently of REALM. To obtain permission to use the REALM, contact Dr. Terry Davis at .

REALM-SF Score Sheet

Select for PDF Version [179 KB]

Patient ID #: _______________    Date: _______________    Examiner Initials: ____________

Behavior   _____
Exercise   _____
Menopause   _____
Rectal   _____
Antibiotics   _____
Anemia   _____
Jaundice   _____

TOTAL SCORE   ______

Administering the REALM-SF:

Suggested Introduction:

"Providers often use words that patients don't understand. We are looking at words providers often use with their patients in order to improve communication between health care providers and patients. Here is a list of medical words.

Starting at the top of the list, please read each word aloud to me. If you don’t recognize a word, you can say 'pass' and move on to the next word."

Interviewer: Give the participant the word list. If the participant takes more than 5 seconds on a words, say "pass" and point to the next word. Hold this scoring sheet so that it is not visible to the participant.

Scores and Grade Equivalents for the REALM-SF

Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50)

The Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50) is a validated health literacy assessment tool containing 50 items designed to assess a Spanish-speaking adult's ability to read and understand common medical terms. Administration of the test takes 3-6 minutes. The SAHLSA was based on the Rapid Estimates of Adult Literacy in Medicine (REALM), known as the most easily administered tool for assessing health literacy in English. However, it is important to note that SAHLSA-50 results are not comparable with REALM results. Users who are interested in comparing the health literacy ability of English and Spanish speakers are advised to adopt SAHL-S&E.

SAHLSA-50 Validation Study: Lee S.-Y. D., Bender D.E., Ruiz R.E., et al. Development of an easy-to-use Spanish health literacy test. HSR 2006 Aug;41(4, Part I); 1392–412. PMID: 16899014 [Full text available in PubMedCentral]

Select for PDF Version [131.77 KB].

SAHLSA-50 Form

Scoring Key to SAHLSA-50 Form

(Correct answers are bolded)

Instructions for Administering SAHLSA-50

Administration of the test could be facilitated by using laminated 4" x 5" flash cards, with each card containing a medical term printed in boldface on the top and the two association words—i.e., the key and the distracter—at the bottom.

Directions to the Interviewer:

1. Before the test, the interviewer should say to the examinee: "Le voy a mostrar tarjetas con 3 palabras en ellas. Primero, me gustaría que usted lea la palabra arriba en voz alta. Entonces, yo leeré las dos palabras debajo a usted y me gustaría que usted me dijera cuál de las dos palabras es más similar a la palabra arriba. Si usted no sabe la respuesta, por favor diga, 'No sé'. No adivine."
2. Show the examinee the first card.
3. The interviewer should say to the examinee: "Ahora, por favor, lea la palabra arriba en voz alta."
4. The interviewer should have a clipboard with a score sheet to record the examinee's answers. The clipboard should be held such that the examinee cannot see or be distracted by the scoring procedure.
5. The interviewer will then read the key and distracter (the two words at the bottom of the card) and then say: "Cuál de las dos palabras es más similar a la palabra arriba? Si usted no sabe la respuesta, por favor diga, 'No sé'.
6. The interviewer may repeat the instructions so that the examinee feels comfortable with the procedure.
7. Continue the test with the rest of the cards.
8. A correct answer for each test item is determined by both correct pronunciation and accurate association. Each correct answer gets one point. Once the test is completed, the interviewer should tally the total points to generate the SAHLSA-50 score.
9. A score between 0 and 37 suggests the examinee has inadequate health literacy.

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