Health Literacy Measurement Tools (Revised)

Fact Sheet

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.

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:

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

SAHL-S Test Form

Stem Key or Distracter "No sé"
(Don't know)
1. empleo __trabajo __educación __No sé
2. convulsiones __mareado __tranquilo __No sé
3. infección __mata __virus __No sé
4. medicamento __instrumento __tratamiento __No sé
5. alcoholismo __adicción __recreo __No sé
6. riñón _orina __fiebre __No sé
7. dosis __dormir __cantidad __No sé
8. aborto espontáneo __pérdida __matrimonio __No sé
9. estreñimiento __bloqueado __suelto __No sé
10. embarazo __parto __niñez __No sé
11. nervios __aburrido __ansiedad __No sé
12. nutrición __saludable __gaseosa __No sé
13. indicado __instrucción __decisión __No sé
14. hormonas __crecimiento __harmonía __No sé
15. abnormal __diferente __similar __No sé
16. diagnóstico __evaluación __recuperación __No sé
17. hemorroides __venas __corazón __No sé
18. sífilis __anticonceptivo __condón __No sé

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

Stem Key or Distracter Don't know
1. kidney __urine __fever __don't know
2. occupation __work __education __don't know
3. medication __instrument __treatment __don't know
4. nutrition __healthy __soda __don't know
5. miscarriage __loss __marriage __don't know
6.infection __plant __virus __don't know
7. alcoholism __addiction __recreation __don't know
8. pregnancy __birth __childhood __don't know
9. seizure __dizzy __calm __don't know
10. dose __sleep __amount __don't know
11. hormones __growth __harmony __don't know
12. abnormal __different __similar __don't know
13. directed __instruction __decision __don't know
14. nerves __bored __anxiety __don't know
15. constipation __blocked __loose __don't know
16. diagnosis __evaluation __recovery __don't know
17. hemorrhoids __veins __heart __don't know
18. syphilis __contraception __condom __don't know

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: This quick tool was developed with AHRQ funding, independently of REALM-R, created by the developers of REALM at Louisiana State University

 

REALM-SF Form

Select for PDF Version [ PDF file - 25.28 KB]

Patient name _______________ Date of birth _______________ Reading level _______________

Date ________________ Examiner _______________ Grade completed _______________

Word  
Menopause
Antibiotics
Exercise
Jaundice
Rectal
Anemia
Behavior

Instructions for Administering the REALM-SF

  1. Give the patient a laminated copy of the REALM-SF form and score answers on an unlaminated copy that is attached to a clipboard. Hold the clipboard at an angle so that the patient is not distracted by your scoring. Say:

    "I want to hear you read as many words as you can from this list. Begin with the first word and read aloud. When you come to a word you cannot read, do the best you can or say, 'blank' and go onto the next word."

  2. If the patient takes more than five seconds on a word, say "blank" and point to the next word, if necessary, to move the patient along. If the patient begins to miss every word, have him or her pronounce only known words.

Scores and Grade Equivalents for the REALM-SF

Score Grade range
0 Third grade and below; will not be able to read most low-literacy materials; will need repeated oral instructions, materials composed primarily of illustrations, or audio or video tapes.
1-3 Fourth to sixth grade; will need low-literacy materials, may not be able to read prescription labels.
4-6 Seventh to eighth grade; will struggle with most patient education materials; will not be offended by low-literacy materials.
7 High school; will be able to read most patient education materials.

 


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 [ PDF file - 131.77 KB]  .

 

SAHLSA-50 Form

Stem Key or Distracter "No sé"
(Don't know)
próstata __glándula __circulación __No sé
empleo __trabajo __educación __No sé
menstrual __mensual __diario __No sé
gripe __sano __enfermo __No sé
avisar __medir __decir __No sé
comidas __cena __paseo __No sé
alcoholismo __adicción __recreo __No sé
grasa __naranja __manteca __No sé
asma __respirar __piel __No sé
cafeína __energía __agua __No sé
osteoporosis __hueso __músculo __No sé
depresión __apetito __sentimientos __No sé
estreñimiento __bloqueado __suelto __No sé
embarazo __parto __niñez __No sé
incesto __familia __vecinos __No sé
pastilla __tableta __galleta __No sé
testículo __óvulo __esperma __No sé
rectal __regadera __inodoro __No sé
ojo __oír __ver __No sé
irritación __rígido __adolorido __No sé
abnormal __diferente __similar __No sé
estrés __preocupación __feliz __No sé
aborto espontáneo __pérdida __matrimonio __No sé
ictericia __amarillo __blanco __No sé
papanicolaou __prueba __vacuna __No sé
impétigo __pelo __piel __No sé
indicado __instrucción __decisión __No sé
ataque __herida __sano __No sé
menopausia __señoras __niñas __No sé
apéndice __rascar __dolor __No sé
comportamiento __pensamiento __conducta __No sé
nutrición __saludable __gaseosa __No sé
diabetes __azúcar __sal __No sé
sífilis __anticonceptivo __condón __No sé
inflamatorio __hinchazón __sudor __No sé
hemorroides __venas __corazón __No sé
herpes __aire __sexo __No sé
alérgico __resistencia __reacción __No sé
riñón __orina __fiebre __No sé
calorías __alimentos __vitaminas __No sé
medicamento __instrumento __tratamiento __No sé
anemia __sangre __nervio __No sé
intestinos __digestión __sudor __No sé
potasio __mineral __proteína __No sé
colitis __intestino __vejiga __No sé
obesidad __peso __altura __No sé
hepatitis __pulmón __hígado __No sé
vesícula biliar __arteria __órgano __No sé
convulsiones __mareado __tranquilo __No sé
artritis __estómago __articulación __No sé

 

Scoring Key to SAHLSA-50 Form

(Correct answers are bolded)

Stem Key or Distracter "No sé"
(Don't know)
1. próstata __glándula __circulación __No sé
2. empleo __trabajo __educación __No sé
3. menstrual __mensual __diario __No sé
4. gripe __sano __enfermo __No sé
5. avisar __medir __decir __No sé
6. comidas __cena __paseo __No sé
7. alcoholismo __adicción __recreo __No sé
8. grasa __naranja __manteca __No sé
9. asma __respirar __piel __No sé
10. cafeína __energía __agua __No sé
11. osteoporosis __hueso __músculo __No sé
12. depresión __apetito __sentimientos __No sé
13. estreñimiento __bloqueado __suelto __No sé
14. embarazo __parto __niñez __No sé
15. incesto __familia __vecinos __No sé
16. pastilla __tableta __galleta __No sé
17. testículo __óvulo __esperma __No sé
18. rectal __regadera __inodoro __No sé
19. ojo __oír __ver __No sé
20. irritación __rígido __adolorido __No sé
21. abnormal __diferente __similar __No sé
22. estrés __preocupación __feliz __No sé
23. aborto espontáneo __pérdida __matrimonio __No sé
24. ictericia __amarillo __blanco __No sé
25. papanicolaou __prueba __vacuna __No sé
26. impétigo __pelo __piel __No sé
27. indicado __instrucción __decisión __No sé
28. ataque __herida __sano __No sé
29. menopausia __señoras __niñas __No sé
30. apéndice __rascar __dolor __No sé
31. comportamiento __pensamiento __conducta __No sé
32. nutrición __saludable __gaseosa __No sé
33. diabetes __azúcar __sal __No sé
34. sífilis __anticonceptivo __condón __No sé
35. inflamatorio __hinchazón __sudor __No sé
36. hemorroides __venas __corazón __No sé
37. herpes __aire __sexo __No sé
38. alérgico __resistencia __reacción __No sé
39. riñón __orina __fiebre __No sé
40. calorías __alimentos __vitaminas __No sé
41. medicamento __instrumento __tratamiento __No sé
42. anemia __sangre __nervio __No sé
43. intestinos __digestión __sudor __No sé
44. potasio __mineral __proteína __No sé
45. colitis __intestino __vejiga __No sé
36. obesidad __peso __altura __No sé
47. hepatitis __pulmón __hígado __No sé
48. vesícula biliar __arteria __órgano __No sé
49. convulsiones __mareado __tranquilo __No sé
50. artritis __estómago __articulación __No sé

 

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.
Page last reviewed November 2014
Internet Citation: Health Literacy Measurement Tools (Revised): Fact Sheet. November 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy/index.html