Health Literacy Assessment Tool

The assessment of literacy ability depends on how literacy is defined and how assessment results are to be used. M ost literature focused on health-literacy issues has focused predominately on assessments of materials and on measures of people’s skills based on their ability to read a sample of these materials.

Two types of standardized literacy assessment tools—word recognition tests and reading comprehension tests—have been widely used to measure patients’ literacy skills. The word recognition test deals with the ability to decode the words. Decoding is the process of transforming the letters into words and being able to pronounce them correctly. This is an essential step in reading. The comprehension skill test deals with how much the patient understand from reading.

Although several literacy assessment tools are available, the Rapid Estimate of Adult Literacy in Medicine (REALM, Davis et al., 1993) (PubMed Abstract) and Test of Functional Health Literacy in Adults ( TOFHLA, Parker et al., 1995) (PubMed Abstract) were developed specifically to measure patients’ health literacy skills.

Word Recognition Test: Rapid Estimate of Adult Literacy in Medicine (REALM)

The REALM is a medical-word recognition and pronunciation test comprising 66 medical terms, arranged in order of complexity by the number of syllables and pronunciation difficulty, starting with simple one-syllable words (eg, pill, eye) and ending with multisyllable words (eg, antibiotics, potassium). Patients read down the list, pronouncing aloud as many words as they can while the examiner scores the number of words pronounced correctly using standard dictionary pronunciation as the scoring standard. Scores on the REALM vary from 0 (no words pronounced correctly) to 66 (all words pronounced correctly.) The score assigns health literacy skills into 4 categories of grade-equivalent reading level: 0–18 (≤3rd grade), 19–44 (4th to 6th grade), 45–60 (7th to 8th grade) and 61–66 (≥9th grade). It can be administered and scored in under 2 minutes by personnel with minimal training, making it easy to use in clinical settings (Adapted from Measurement Excellence and Training Resource Information Center. Critical review of Rapid Estimate of Adult Literacy in Medicine (REALM).

The REALM sample kit (instruction manual, laminated patient word lists, scoring sheets) is available for purchase from Terry C. Davis, PhD ( LSU Medical Center, 1501 Kings Highway, Shreveport, LA 71130-3932,

Sample REALM test

Reading Comprehension Test: Test of Functional Health Literacy in Adults (TOFHLA)

The TOFHLA measures the functional literacy level of patients, using real-to-life health care materials. These materials include patient education information, prescription bottle labels, registration forms, and instructions for diagnostic tests. The TOFHLA assesses two main constructs, numeracy and reading comprehension; it has a total of 67 items. The numeracy scale, used to measure the ability to read and understand numbers, includes 17 items; the reading comprehension scale, used to measure the patient’s ability to read and understand health care-related passages, contains 50 items. The reading comprehension scale utilizes the Cloze procedure, a technique that presents the patient with reading passages that are missing every fifth to seventh word; the patient must then select the appropriate missing word from a list of four possible answers. Only one choice is correct with regard to grammar or the context of the sentence.

In the reading comprehension section, patients are asked to select the correct response from a list of four possible choices. Responses are reviewed for accuracy, and each item answered correctly is assigned a score of one. Incorrect items are given a score of zero. The numeracy section is scored with the same dichotomous scale process of one (for correct responses) and zero (for incorrect responses). Raw scores are converted to scaled scores, which range from 0-100. The numeracy items are summed, and their total multiplied by 2.941 so as to create scores that range from 0-50; reading comprehension items are summed (range: 0-50) and are then added to the scaled numeracy score. To interpret the total score, participants receiving a score of 59 or below are considered to have inadequate functional health literacy; those scoring 60-74 have marginal functional health literacy, and subjects scoring 75 and above have adequate functional health literacy.

There are two additional versions of the TOFHLA: TOFHLA-S, a validated Spanish translation, and the S-TOFHLA, a short form that requires up to 12 minutes to administer. The short form is composed of 4 numeracy items and 36 reading comprehension items. (Adapted from Measurement Excellence and Training Resource Information Center. Critical review of Test of Functional Health Literacy in Adults (TOFHLA).

The TOFHLA is available for purchase from at $50.


From a psychometric perspective, neither the REALM nor the TOFHLA capture the complexity of the construct of health literacy. They are both indicators of reading skills (word recognition or reading comprehension and numeracy), rather than measures of the full range of skills needed for health literacy (cultural and conceptual knowledge, listening, speaking, numeracy, writing and reading). Current assessment tools and research findings cannot differentiate among (a) reading ability, (b) lack of background knowledge in health-related domains, such as biology, (c) lack of familiarity with language and types of materials, or (d) cultural differences in approaches to health and health care. In addition, no current measures of health literacy include oral communication skills or writing skills and none measure the health literacy demands on individuals within different health contexts.