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Instrument Summary for Health Literacy

Please note that this section is an archive and is no longer being updated.

Development: Parker et al. developed the TOFHLA in 1995 through use of actual hospital medical texts as the source for its numeracy and reading comprehension items. The TOFHLA has a total of 67 items, and it assesses both reading comprehension and numeracy constructs. The reading comprehension items are formatted in multiple-choice responses and the numeracy items have dichotomous response scales.

Purpose: To measure the functional health literacy in patients using real-life health care literature. The literature includes: patient education information, prescription bottle labels, registration forms, and instructions for diagnostic tests.

Useful Facts: The TOFHLA reading comprehension scale is self-administered and the numeracy scale is interviewer-administered. The reading comprehension scale uses a method referred to as the Cloze procedure where the patient is presented with reading passages that are missing every fifth to seventh word. The patient must choose the correct missing word from a list of four possible answers with respect to grammar or the context of the sentence.

Other versions of the TOFHLA that have been validated include: the Spanish TOFHLA (TOFHLA-S) and the Short TOFHLA (S-TOFHLA).

VA Relevance: The TOFHLA has been used with veterans to assess health literacy.

Availability: The TOFHLA is available for purchase from Peppercorn Books.

References

1. Parikh NS, Parker RM, Nurss JR, Baker DW, & Williams MV. Shame and health literacy: the unspoken connection. Patient Education and Counseling 1996;27:33-9. [Abstract]
2. Parker RM, Baker DW, Williams MV, & Nurss JR. The Test of Functional Health Literacy in Adults: a new instrument for measuring patients' literacy skills. J Gen Intern Med 1995;10:537-41. [Abstract]
3. Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, & Nurss JR. Inadequate functional health literacy among patients at two public hospitals. JAMA 1995 Dec 6; 274(21):1677-82. [Abstract]

Development: The WRAT-R is commonly used in educational settings, but the reading subscale has been used in the medical field to measure health literacy. The test assesses word recognition by having the person read aloud from a list of words. When 10 consecutive words are mispronounced, the test concludes and a score is derived.

Purpose: The WRAT-R is an individual achievement test that assesses skills in reading, spelling, and arithmetic.

Useful Facts: The WRAT-R is appropriate for people aged 5 to adults. It takes approximately 15 to 30 minutes to complete. A raw score is computed for each scale by summing the number of correct answers, and then the raw score may be converted to a grade equivalent score and a standard score. Standard scores have a mean of 100 and standard deviation of 16.

VA Relevance: The WRAT-R has been used with veterans to assess health literacy.

Availability: There are different versions of the WRAT available, such as the WRAT-3, WRAT-E (expanded), and computerized versions. The WRAT-3 is available from PAR, Inc.

References

1. Friedenberg L. Psychological Testing: Design, Analysis, and Use. 1995; Allyn and Bacon: Massachusetts.
2. Jastak, S., & Wilkinson, G. S. (1987). Wide range achievement test-revised. Wilmington, DE: Jastak Associates.
3. Kareken DA, Gur RC, Saykin AJ. Reading on the Wide Range Achievement Test-Revised and parental education as predictors of IQ: comparison with the Barona formula. Arch Clin Neuropsychol. 1995 Mar;10(2):147-57. [Abstract]

Development: The original REALM contained 125 words chosen based on patient educational materials and intake forms used in primary care clinics. It was then piloted for three years using public health and primary care settings in five states. Physicians suggested that the REALM be shortened to increase its practicality, thus item analysis was performed, and the REALM was reduced to the current 66-item version. It was specifically developed to identify patients that read at levels below ninth grade.

Purpose: To provide an objective measure of patient reading ability that would be appropriate for medical settings.

Useful Facts: The REALM does not measure patient's understanding. Words that are mispronounced or not attempted are counted as wrong; however, words that are pronounced correctly or attempted but pronounced incorrectly are counted as right. The REALM suggests that a patient with a reading level below ninth grade has low literacy skills and should be given additional verbal directions and instructions.

It has 66 items and there are 3 columns with 22 words per column; the words are arranged by the number of syllables and level of difficulty. A shortened version of the REALM is known as the REALM-Revised (REALM-R); it has 8 items.

VA Relevance:1. The REALM has been used with veterans to assess health literacy.

Availability: To receive a sample kit (instruction manual, laminated patient word lists, scoring sheets), write to:
Terry C. Davis, PhD
LSU Medical Center
1501 Kings Highway
Shreveport, LA 71130-3932.

Please contact developer for updated price.

References

1. Bass III PF, Wilson JF, Griffith CH. A shortened Instrument for literacy screening. J Gen Intern Med 2001;16:117 [Abstract]
2. Davis TC, Crouch MA, Long SW, Jackson RH, Bates P, George RB, Bairnsfather LE. Rapid assessment of literacy levels of adult primary care patients. Fam Med 1991 Aug;23(6):433-5. [Abstract]
3. Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, Crouch MA. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med 1993 Jun;25(6):391-5. [Abstract]