Quick and Valid Tools for Measuring Health Literacy

“The average American adult reads between the 8th- and 9th-grade reading level; whereas, most patient education materials are written at, or above, the 10th-grade reading level.” —National Center for Education Statistics, U.S. Department of Education

What Is Health Literacy and Why Do We Need to Measure It?

The Institute of Medicine defines health literacy as the ability to obtain, process, and understand basic health information and services needed to make appropriate health decisions.¹ Many health care providers assess skills in basic literacy using a self-report of the patient’s highest grade level completed in school. This method is unreliable.² A valid assessment should measure skills in basic literacy, such as word recognition, reading comprehension, and numeracy. while the patient is reading health-related information.

Health Literacy and Health Outcomes

Low health literacy is a significant problem in the United States. According to the American Medical Association, more than one-third of adults in the United States—approximately 89 million people—have inadequate health literacy.³ The consequences of limited health literacy include, but are not limited to, billions of dollars in additional health care costs and poor health outcomes.

Low health literacy impacts health outcomes in two ways:

• A mismatch between reading abilities and the reading level of written health information
• A lack of health-related information that is easy to understand

Barriers to Health Literacy

Existing literature has shown that most written patient education materials provided at the point of care are too complex for the average American patient to understand.⁴ A discrepancy exists between the readability (or grade level) of patient education materials and the average American adult’s capacity to comprehend written health-related information. Most patient education materials are written at or above the 10th-grade reading level; whereas, most adults read between the 8th- and 9th-grade level.⁵

Most patients with limited health literacy remain undetected by the healthcare system. It is essential to identify patients with limited health literacy to guide the development and selection of patient education materials that are easy to understand.

Quick and Valid Tools for Measuring Health Literacy

Patients with limited literacy skills can be challenging to identify. The following tools provide a quick and valid measurement of health literacy in clinical settings.

Rapid Estimate of Adult Literacy in Medicine – Short Form (REALM-SF) provides a quick screening of health literacy using word recognition and comprehension of a seven-item word list.⁶ Patients are instructed to read aloud as many words as they can. Words that take more than five seconds to decode are skipped. Scores are interpreted into reading grade level equivalents, or the reading skill level required to understand the written text. Administration takes approximately one minute, and minimal training is required.

Brief Health Literacy Screening Tool (BRIEF) uses self-report of problems related to reading, comprehension, need for assistance, and confidence to assess health literacy.⁷ The assessment consists of four questions, each worth one to five points. Scores are interpreted as health literacy levels (limited, marginal, or adequate). Administration takes one to two minutes, and minimal training is required.

Short Assessment of Health Literacy – Spanish and English (SAHL – S&E) uses word recognition skills, such as comprehension and pronunciation of health-related terms, to assess health literacy in Spanish- and English-speaking adults.⁸ The assessment consists of 18 health-related test terms presented alongside two association words: one keyword with a related meaning and one unrelated distractor word. Patients are instructed to select the word that is most similar to the health-related test term. Scores fall into one of two health literacy categories: adequate (15 or more correct answers) or inadequate (less than 15 correct answers). Administration takes two to three minutes, and minimal training is required.