In the realm of healthcare, clear communication is paramount. Patients who understand medical information are better equipped to manage their health, adhere to treatment plans, and make informed decisions. However, a significant portion of the population struggles with health literacy, creating a barrier to effective healthcare. Health Care Literacy Tools are essential resources designed to bridge this gap, enabling healthcare professionals to assess patient understanding and tailor communication strategies accordingly. This article delves into key health literacy assessment tools provided by the Agency for Healthcare Research and Quality (AHRQ), offering valuable resources for improving patient outcomes and enhancing the overall healthcare experience.
The tools highlighted below, developed and supported by AHRQ, are freely available for use without requiring any permission, emphasizing AHRQ’s commitment to promoting health literacy. Attribution to AHRQ as the source is appreciated, and researchers utilizing these tools for publication are encouraged to cite the original development and validation papers linked with each tool. It’s important to note that while these tools have primarily been used in research settings, certain tools like the Rapid Estimate of Adult Literacy in Medicine–Short Form (REALM-SF) are specifically designed for clinical use to identify patients with limited literacy.
These AHRQ-backed instruments are specifically tailored for assessing personal health literacy in both English and Spanish speakers, acknowledging the linguistic diversity prevalent in the United States. Translating these tools into other languages requires careful consideration and is not recommended without consulting AHRQ’s Office of Communications and Knowledge Transfer for guidance and expert consultation to ensure the validity of the assessment in a new linguistic context.
For those seeking a broader range of health literacy measures, the Health Literacy Tool Shed, funded by the U.S. National Libraries of Medicine, offers an extensive collection of resources and assessment tools.
Short Assessment of Health Literacy–Spanish and English (SAHL-S&E)
The Short Assessment of Health Literacy–Spanish and English (SAHL–S&E) stands out as a robust and efficient tool for evaluating health literacy in both English and Spanish. This tool provides comparable assessments in both languages, ensuring reliable and valid results across diverse populations. The SAHL–S&E is designed for ease of administration, requiring only 2-3 minutes to complete and minimal training for healthcare staff.
The test involves presenting individuals with 18 medical terms, one at a time. For each term, the individual is asked to read it aloud and then choose the word that is closest in meaning from two provided options: a key word with a related meaning and a distractor word with an unrelated meaning. This method effectively assesses both the individual’s pronunciation and comprehension of health-related vocabulary. The use of laminated 4”x5” flashcards is recommended to simplify the administration process, with each card displaying a medical term in bold at the top and the two word choices (key and distractor) at the bottom.
SAHL-S test form example showing the structure with stem word, key/distractor options and “Don’t know” option.
The SAHL-S Test Form and User’s Guide, along with the SAHL-E Test Form and User’s Guide, are readily accessible in PDF format, providing comprehensive instructions and materials for implementation.
SAHL-S Test Form
The SAHL-S test form includes 18 items, each presenting a medical term (Stem) alongside two options: a Key word that is related in meaning and a Distracter word that is unrelated. Test-takers are also given a “No sé” (Don’t know) option. The table below illustrates the structure of the SAHL-S test.
| Stem | Key or Distracter | “No sé” (Don’t know) |
|---|---|---|
| 1. empleo | __trabajo | __educación |
| 2. convulsiones | __mareado | __tranquilo |
| 3. infección | __mata | __virus |
| 4. medicamento | __instrumento | __tratamiento |
| 5. alcoholismo | __adicción | __recreo |
| 6. riñón | _orina | __fiebre |
| 7. dosis | __dormir | __cantidad |
| 8. aborto espontáneo | __pérdida | __matrimonio |
| 9. estreñimiento | __bloqueado | __suelto |
| 10. embarazo | __parto | __niñez |
| 11. nervios | __aburrido | __ansiedad |
| 12. nutrición | __saludable | __gaseosa |
| 13. indicado | __instrucción | __decisión |
| 14. hormonas | __crecimiento | __harmonía |
| 15. abnormal | __diferente | __similar |
| 16. diagnóstico | __evaluación | __recuperación |
| 17. hemorroides | __venas | __corazón |
| 18. sífilis | __anticonceptivo | __condón |
Table presenting the SAHL-S test form items, demonstrating the stem words, key and distractor options, and “Don’t know” choice.
These 18 SAHL-S items are carefully ordered by difficulty, and the answer key is available separately to facilitate scoring and interpretation.
Instruction for Administering SAHL-S
Administering the SAHL-S tool requires a structured approach to ensure accurate and consistent results. The recommended method involves using flashcards and following a specific script for the interviewer. Crucially, the entire list of words should not be presented to the individual at once. The interviewer should guide the examinee through each card individually, ensuring a clear and comfortable testing environment.
| 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. |
Instructions provided for interviewers to administer the SAHL-S assessment, including pre-test instructions and scoring guidelines.
Correct answers are determined by both accurate pronunciation and correct association of the medical term with the appropriate key word. Scores range from 0 to 18, with a score of 14 or below indicating inadequate health literacy.
SAHL-E Word Sets & User’s Guide
Similar to the Spanish version, the SAHL-E provides a set of 18 English medical terms designed to assess health literacy in English speakers. The structure mirrors the SAHL-S, with each item including a stem word, a key, a distractor, and a “Don’t know” option.
| Stem | Key or Distracter | Don’t know |
|---|---|---|
| 1. kidney | __urine | __fever |
| 2. occupation | __work | __education |
| 3. medication | __instrument | __treatment |
| 4. nutrition | __healthy | __soda |
| 5. miscarriage | __loss | __marriage |
| 6.infection | __plant | __virus |
| 7. alcoholism | __addiction | __recreation |
| 8. pregnancy | __birth | __childhood |
| 9. seizure | __dizzy | __calm |
| 10. dose | __sleep | __amount |
| 11. hormones | __growth | __harmony |
| 12. abnormal | __different | __similar |
| 13. directed | __instruction | __decision |
| 14. nerves | __bored | __anxiety |
| 15. constipation | __blocked | __loose |
| 16. diagnosis | __evaluation | __recovery |
| 17. hemorrhoids | __veins | __heart |
| 18. syphilis | __contraception | __condom |
Table displaying the SAHL-E word sets, including stem words, key and distractor options, and “Don’t know” choice.
Like the SAHL-S, the SAHL-E items are ordered by difficulty, and a separate answer key is available for scoring purposes.
Instructions for Administering SAHL-E
The administration of SAHL-E follows a similar protocol to SAHL-S, utilizing flashcards and a standardized script for interviewers. Maintaining consistency in administration is crucial for the reliability of the assessment.
| 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. |
Instructions for administering the SAHL-E assessment, including pre-test instructions for the interviewer and scoring guidelines.
Similar to SAHL-S, correct responses in SAHL-E require both accurate pronunciation and appropriate association. Scores range from 0 to 18, and a score of 14 or less indicates low health literacy in English.
Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF)
The Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF) offers a swift and valid method for clinicians to assess patient health literacy. This 7-item word recognition test provides a practical solution for busy clinical settings, delivering a reliable indication of a patient’s literacy level in relation to medical terminology. The REALM-SF has undergone rigorous validation and field testing across diverse research environments, demonstrating strong agreement with the longer 66-item REALM instrument in terms of grade-level assignments.
REALM-SF score sheet example showing patient ID, date, examiner initials and list of words to assess.
The REALM-SF Score Sheet is available in PDF format, providing a convenient and printable resource for clinicians.
It is important to note that while REALM-SF was developed with AHRQ funding, it is independent of the REALM tool. Permissions to use the full REALM instrument should be obtained directly from Dr. Terry Davis.
REALM-SF Score Sheet
The REALM-SF score sheet is designed for ease of use in clinical settings. It includes space to record patient identification information, the date of assessment, and examiner initials. The core of the score sheet is a list of seven medical words to be administered to the patient.
| Note: The REALM-SF was developed with AHRQ funding, independently of REALM. To obtain permission to use the REALM, contact Dr. Terry Davis at [email protected]. |
Note clarifying the independent development of REALM-SF from REALM and instructions for obtaining permission to use REALM.
The score sheet itself is straightforward, focusing on the essential elements for quick assessment and scoring.
Administering the REALM-SF
Administering the REALM-SF is designed to be efficient and patient-friendly. The suggested introduction aims to create a comfortable environment and explain the purpose of the assessment in improving communication. The process involves asking the patient to read aloud a list of medical words, with the interviewer noting any words the patient struggles with or cannot pronounce.
| 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. |
Suggested introduction for administering the REALM-SF assessment, designed to put patients at ease and explain the test’s purpose.
The interviewer should encourage the patient to “pass” on any words they don’t recognize, ensuring the assessment remains rapid and avoids causing patient distress.
Scores and Grade Equivalents for the REALM-SF
The scoring of REALM-SF provides a grade-level equivalent for health literacy, offering a practical interpretation of the patient’s literacy skills in a healthcare context. This grade-level equivalency helps clinicians understand the type of materials and communication approaches best suited for each patient.
| 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. |
Table outlining REALM-SF scores and their corresponding grade level ranges, along with implications for patient education and communication strategies.
Scores range from 0 to 7, with each score range corresponding to a specific grade level and providing guidance on appropriate patient education strategies, from needing primarily visual or audio materials to being able to comprehend most patient education resources.
Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50)
The Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50) is specifically designed to assess the health literacy of Spanish-speaking adults. This validated tool comprises 50 items and evaluates an individual’s ability to read and comprehend common medical terms in Spanish. Administering the SAHLSA-50 typically takes between 3 to 6 minutes. While SAHLSA-50 is based on the principles of the Rapid Estimates of Adult Literacy in Medicine (REALM), it is crucial to recognize that SAHLSA-50 results are not directly comparable to REALM scores. For users intending to compare health literacy levels between English and Spanish speakers, the SAHL-S&E is the recommended tool.
SAHLSA-50 form example showing stem word, key/distractor options, and “No sé” option in Spanish.
The SAHLSA-50 Form is available in PDF format, providing a printable version of the assessment tool.
SAHLSA-50 Form
The SAHLSA-50 form includes 50 items, each presenting a medical term in Spanish (Stem) along with two word choices: a Key word and a Distracter word, as well as a “No sé” (Don’t know) option. The structure is similar to SAHL-S and SAHL-E, but with a more extensive set of terms to provide a more detailed assessment.
| Stem | Key or Distracter | “No sé” (Don’t know) |
|---|---|---|
| próstata | __glándula | __circulación |
| empleo | __trabajo | __educación |
| menstrual | __mensual | __diario |
| gripe | __sano | __enfermo |
| avisar | __medir | __decir |
| comidas | __cena | __paseo |
| alcoholismo | __adicción | __recreo |
| grasa | __naranja | __manteca |
| asma | __respirar | __piel |
| cafeína | __energía | __agua |
| osteoporosis | __hueso | __músculo |
| depresión | __apetito | __sentimientos |
| estreñimiento | __bloqueado | __suelto |
| embarazo | __parto | __niñez |
| incesto | __familia | __vecinos |
| pastilla | __tableta | __galleta |
| testículo | __óvulo | __esperma |
| rectal | __regadera | __inodoro |
| ojo | __oír | __ver |
| irritación | __rígido | __adolorido |
| abnormal | __diferente | __similar |
| estrés | __preocupación | __feliz |
| aborto espontáneo | __pérdida | __matrimonio |
| ictericia | __amarillo | __blanco |
| papanicolaou | __prueba | __vacuna |
| impétigo | __pelo | __piel |
| indicado | __instrucción | __decisión |
| ataque | __herida | __sano |
| menopausia | __señoras | __niñas |
| apéndice | __rascar | __dolor |
| comportamiento | __pensamiento | __conducta |
| nutrición | __saludable | __gaseosa |
| diabetes | __azúcar | __sal |
| sífilis | __anticonceptivo | __condón |
| inflamatorio | __hinchazón | __sudor |
| hemorroides | __venas | __corazón |
| herpes | __aire | __sexo |
| alérgico | __resistencia | __reacción |
| riñón | __orina | __fiebre |
| calorías | __alimentos | __vitaminas |
| medicamento | __instrumento | __tratamiento |
| anemia | __sangre | __nervio |
| intestinos | __digestión | __sudor |
| potasio | __mineral | __proteína |
| colitis | __intestino | __vejiga |
| obesidad | __peso | __altura |
| hepatitis | __pulmón | __hígado |
| vesícula biliar | __arteria | __órgano |
| convulsiones | __mareado | __tranquilo |
| artritis | __estómago | __articulación |
*Table showing a section of the SAHLSA-50 form with Spanish medical terms, key and distractor options, and “No sé” choice.*
The 50 items in SAHLSA-50 offer a comprehensive assessment of Spanish health literacy, covering a wide range of medical vocabulary.
Scoring Key to SAHLSA-50 Form
The scoring key for SAHLSA-50 provides the correct answers for each item, simplifying the scoring process. Correct answers are bolded in the key to facilitate quick identification and tallying of the score.
| Stem | Key or Distracter | “No sé” (Don’t know) |
|---|---|---|
| 1. próstata | __glándula | __circulación |
| 2. empleo | __trabajo | __educación |
| 3. menstrual | __mensual | __diario |
| 4. gripe | __sano | __enfermo |
| 5. avisar | __medir | __decir |
| 6. comidas | __cena | __paseo |
| 7. alcoholismo | __adicción | __recreo |
| 8. grasa | __naranja | __manteca |
| 9. asma | __respirar | __piel |
| 10. cafeína | __energía | __agua |
| 11. osteoporosis | __hueso | __músculo |
| 12. depresión | __apetito | __sentimientos |
| 13. estreñimiento | __bloqueado | __suelto |
| 14. embarazo | __parto | __niñez |
| 15. incesto | __familia | __vecinos |
| 16. pastilla | __tableta | __galleta |
| 17. testículo | __óvulo | __esperma |
| 18. rectal | __regadera | __inodoro |
| 19. ojo | __oír | __ver |
| 20. irritación | __rígido | __adolorido |
| 21. abnormal | __diferente | __similar |
| 22. estrés | __preocupación | __feliz |
| 23. aborto espontáneo | __pérdida | __matrimonio |
| 24. ictericia | __amarillo | __blanco |
| 25. papanicolaou | __prueba | __vacuna |
| 26. impétigo | __pelo | __piel |
| 27. indicado | __instrucción | __decisión |
| 28. ataque | __herida | __sano |
| 29. menopausia | __señoras | __niñas |
| 30. apéndice | __rascar | __dolor |
| 31. comportamiento | __pensamiento | __conducta |
| 32. nutrición | __saludable | __gaseosa |
| 33. diabetes | __azúcar | __sal |
| 34. sífilis | __anticonceptivo | __condón |
| 35. inflamatorio | __hinchazón | __sudor |
| 36. hemorroides | __venas | __corazón |
| 37. herpes | __aire | __sexo |
| 38. alérgico | __resistencia | __reacción |
| 39. riñón | __orina | __fiebre |
| 40. calorías | __alimentos | __vitaminas |
| 41. medicamento | __instrumento | __tratamiento |
| 42. anemia | __sangre | __nervio |
| 43. intestinos | __digestión | __sudor |
| 44. potasio | __mineral | __proteína |
| 45. colitis | __intestino | __vejiga |
| 36. obesidad | __peso | __altura |
| 47. hepatitis | __pulmón | __hígado |
| 48. vesícula biliar | __arteria | __órgano |
| 49. convulsiones | __mareado | __tranquilo |
| 50. artritis | __estómago | __articulación |
Table showing the scoring key for SAHLSA-50, with correct answers bolded for easy reference.
This scoring key is essential for accurate and efficient assessment using the SAHLSA-50 tool.
Instructions for Administering SAHLSA-50
The administration of SAHLSA-50, similar to SAHL-S and SAHL-E, benefits from using flashcards and a standardized protocol for interviewers. Consistency in administration is key to ensuring reliable results.
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:
- 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 SAHLSA-50 score.
- A score between 0 and 37 suggests the examinee has inadequate health literacy.
Instructions for administering the SAHLSA-50 assessment, including pre-test instructions and scoring guidelines for interviewers.
Scores on the SAHLSA-50 range from 0 to 50, with a score of 37 or below indicating inadequate health literacy in Spanish.
By utilizing these valuable health care literacy tools, healthcare providers can gain crucial insights into their patients’ understanding of medical information. This understanding empowers them to adapt their communication strategies, ensuring patients receive the information they need in a format they can comprehend. Ultimately, these tools contribute to improved patient engagement, better health outcomes, and a more equitable and effective healthcare system.
