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Personal Health Literacy Measurement Tools

Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. AHRQ-funded researchers have developed tools to measure an aspect of personal health literacy—individuals' reading comprehension in a medical context.

The tools available from AHRQ are the:

These tools are free and do not require permission to use. Please credit 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.) These tools have largely been used for research. Only the Rapid Estimate of Adult Literacy in Medicine–Short Form was developed to identify patients with limited literacy in clinical settings.

The AHRQ-supported tools are for the assessment of personal health literacy in speakers of English and Spanish, the languages most frequently spoken in the United States. Translation of these tools into another language may not produce a valid assessment of personal health literacy in the new language. Please contact AHRQ's for permission and to be put in contact with a technical expert before attempting a translation.

For additional measures of personal health literacy, go to the , funded by the U.S. National Libraries of Medicine.

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

The Short Assessment of Health Literacy–Spanish and English (SAHL–S&E) consists of comparable tests in English and Spanish, with good reliability and validity in both languages. You present people being assessed with 18 test terms, one at a time. You ask people to read the test term aloud and choose the word closer in meaning to the test term from two options – 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 of health-related terms. Administration of the test takes only 2-3 minutes and requires minimal training. Using laminated 4”-by-5” flash cards makes administering the test easier. Each card contains a medical test term printed in boldface on the top and the two options—i.e., the key and the distracter words —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

Stem Key or Distracter "No sé"
(Don't know)
1. empleo __trabajo ܳó __No sé
2. convulsiones __mareado __tranquilo __No sé
3. infección __mata __virus __No sé
4. medicamento __instrumento __tratamiento __No sé
5. alcoholismo 岹徱ó __recreo __No sé
6. ñó _orina __fiebre __No sé
7. dosis __dormir __cantidad __No sé
8. aborto espontáneo é徱岹 __matrimonio __No sé
9. ٰñԳٴ __bloqueado __suelto __No sé
10. embarazo __parto Ծñ __No sé
11. nervios __aburrido __ansiedad __No sé
12. Գٰܳó __saludable __gaseosa __No sé
13. indicado 徱Բٰܳó 𳦾ó __No sé
14. hormonas __crecimiento 󲹰Dzí __No sé
15. abnormal __diferente __similar __No sé
16. diagnóstico 𱹲ܲó 𳦳ܱó __No sé
17. hemorroides __venas 峦ǰó __No sé
18. íھ __anticonceptivo 峦DzԻó __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 settings, 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 tdavis1@lsuhsc.edu.

 

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

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 [131.77 KB].

 

SAHLSA-50 Form

Stem Key or Distracter "No sé"
(Don't know)
óٲٲ 岵áԻܱ 峦ܱó __No sé
empleo __trabajo ܳó __No sé
menstrual __mensual __diario __No sé
gripe __sano __enfermo __No sé
avisar __medir __decir __No sé
comidas __cena __paseo __No sé
alcoholismo 岹徱ó __recreo __No sé
grasa __naranja __manteca __No sé
asma __respirar __piel __No sé
ڱíԲ Աí __agua __No sé
osteoporosis __hueso 峾úܱ __No sé
ó __apetito __sentimientos __No sé
ٰñԳٴ __bloqueado __suelto __No sé
embarazo __parto Ծñ __No sé
incesto __familia __vecinos __No sé
pastilla __tableta __galleta __No sé
ٱíܱ óܱ __esperma __No sé
rectal __regadera __inodoro __No sé
ojo í __ver __No sé
ٲó í __adolorido __No sé
abnormal __diferente __similar __No sé
ٰé dzܱ貹ó __feliz __No sé
aborto espontáneo é徱岹 __matrimonio __No sé
ictericia __amarillo __blanco __No sé
papanicolaou __prueba __vacuna __No sé
éپ __pelo __piel __No sé
indicado 徱Բٰܳó 𳦾ó __No sé
ataque __herida __sano __No sé
menopausia ñǰ Ծñ __No sé
éԻ徱 __rascar __dolor __No sé
comportamiento __pensamiento __conducta __No sé
Գٰܳó __saludable __gaseosa __No sé
diabetes 岹ú __sal __No sé
íھ __anticonceptivo 峦DzԻó __No sé
inflamatorio 󾱲Գ󲹳ó __sudor __No sé
hemorroides __venas 峦ǰó __No sé
herpes __aire __sexo __No sé
é __resistencia 𲹳ó __No sé
ñó __orina __fiebre __No sé
ǰí __alimentos __vitaminas __No sé
medicamento __instrumento __tratamiento __No sé
anemia __sangre __nervio __No sé
intestinos 徱پó __sudor __No sé
potasio __mineral dzٱíԲ __No sé
colitis __intestino __vejiga __No sé
obesidad __peso __altura __No sé
hepatitis ܱó í __No sé
vesícula biliar __arteria óԴ __No sé
convulsiones __mareado __tranquilo __No sé
artritis ó 岹پܱó __No sé

 

Scoring Key to SAHLSA-50 Form

(Correct answers are bolded)

Stem Key or Distracter "No sé"
(Don't know)
1. óٲٲ 岵áԻܱ 峦ܱó __No sé
2. empleo __trabajo ܳó __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 岹徱ó __recreo __No sé
8. grasa __naranja __manteca __No sé
9. asma __respirar __piel __No sé
10. ڱíԲ Աí __agua __No sé
11. osteoporosis __hueso 峾úܱ __No sé
12. ó __apetito __sentimientos __No sé
13. ٰñԳٴ __bloqueado __suelto __No sé
14. embarazo __parto Ծñ __No sé
15. incesto __familia __vecinos __No sé
16. pastilla __tableta __galleta __No sé
17. ٱíܱ óܱ __esperma __No sé
18. rectal __regadera __inodoro __No sé
19. ojo í __ver __No sé
20. ٲó í __adolorido __No sé
21. abnormal __diferente __similar __No sé
22. ٰé dzܱ貹ó __feliz __No sé
23. aborto espontáneo é徱岹 __matrimonio __No sé
24. ictericia __amarillo __blanco __No sé
25. papanicolaou __prueba __vacuna __No sé
26. éپ __pelo __piel __No sé
27. indicado 徱Բٰܳó 𳦾ó __No sé
28. ataque __herida __sano __No sé
29. menopausia ñǰ Ծñ __No sé
30. éԻ徱 __rascar __dolor __No sé
31. comportamiento __pensamiento __conducta __No sé
32. Գٰܳó __saludable __gaseosa __No sé
33. diabetes 岹ú __sal __No sé
34. íھ __anticonceptivo 峦DzԻó __No sé
35. inflamatorio 󾱲Գ󲹳ó __sudor __No sé
36. hemorroides __venas 峦ǰó __No sé
37. herpes __aire __sexo __No sé
38. é __resistencia 𲹳ó __No sé
39. ñó __orina __fiebre __No sé
40. ǰí __alimentos __vitaminas __No sé
41. medicamento __instrumento __tratamiento __No sé
42. anemia __sangre __nervio __No sé
43. intestinos 徱پó __sudor __No sé
44. potasio __mineral dzٱíԲ __No sé
45. colitis __intestino __vejiga __No sé
36. obesidad __peso __altura __No sé
47. hepatitis ܱó í __No sé
48. vesícula biliar __arteria óԴ __No sé
49. convulsiones __mareado __tranquilo __No sé
50. artritis ó 岹پܱó __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 December 2022
Page originally created November 2019

Internet Citation: Personal Health Literacy Measurement Tools . Content last reviewed December 2022. Agency for Healthcare Research and Quality, Rockville, MD.
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