Key points:

• There are many tools to measure the health literacy of individuals, communities and populations.
• Understanding these tools can increase your knowledge of health literacy.
• It is rarely useful or practical to assess individual health literacy in clinical settings. It is not generally necessary and can be counterproductive.
• A universal precautions approach is the most effective way to support your patients’ health literacy.

Health literacy assessment tools

There are many validated tools to measure health literacy at individual, community and population levels. Each has strengths and limitations and is suited to different purposes. Understanding these tools can increase your knowledge of health literacy.

The Health Literacy Tool Shed is an online database of health literacy measurement tools. It contains some basic information about the tools based on peer reviewed literature. There are approximately 200 measurement tools on the site.

Many of the measurement tools are not freely available, and some involve a fee to use.

Most of the assessment tools have not been validated in Australia.

Issues with assessment tools

Many individual health literacy assessment tools measure features that are thought to be markers for a person’s health literacy capacity, such as general literacy and numeracy skills [i]. However, other factors that are harder to measure have a significant influence on individual health literacy, such as:

• knowledge of health and scientific concepts,
• cultural understandings of health and wellbeing,
• confidence and communication skills,
• decision making and reasoning skills,
• understanding of the consumers role in medical decision making, and
• motivation or level of engagement.

These factors are less often and less easily measured [ii].

Australian assessment tools

The Ophelia project (Optimising Health Literacy and Access), run as a collaboration between Deakin University, Monash University, the Victorian Government and eight community sector organisations in Victoria, has developed a range of health literacy tools for Australia. The tools have been tested and validated in a number of different settings and countries. The tools include:

• Health Literacy Questionnaire (HLQ):

Measures broad components that contribute to individual health literacy, rather than just literacy and numeracy skills.

Provides information about what needs to be done to improve systems and services to support health literacy [i].

The Australian Bureau of Statistics used the HLQ in the most recent national survey of health literacy [ii].

It can be used for both individuals and communities.

• Health Education Impact Questionnaire (heiQ):

Evaluates health education and self-management programs

• Information and Support for Health Actions Questionnaire (ISHA-Q):

Can be used for individuals and communities

Was designed for cultures that often make decisions as a group

• eHealth Literacy Questionnaire (eHLQ):
• Readiness and Enablement Index for Health Technology (READHY):
• Organisational Health Literacy Responsiveness Tool (Org-HLR):

Helps organisations assess strengths and areas for further development in relation to systems, processes and practices

Suits all organisations that play a role in providing health and health-related information, services and programs to individuals and communities

You can find out more about the tools and request access to them from the Centre for Global Health and Equity at Swinburne University.

Assessing health literacy in clinical settings

Assessing the health literacy of individual patients is not recommended. It can cause harm to patients and damage the relationship between patients and clinicians. This risk usually outweighs the benefits of assessment.[v][vi][vii]. Harm to patients can arise from shame, stigma and alienation caused by testing.  The universal precautions approach to health literacy removes the need to assess individual consumers unless there is a clear benefit to the patient that outweighs the potential shame and embarrassment.

If you do decide to test patients, it is important to consider that an individual’s health literacy can vary significantly depending on their health status, the setting and demands on their emotional or cognitive capacity. For example, an individual’s health literacy skills will be challenged if they are unwell, sleep deprived, have just received a serious diagnosis, or are affected by medications.

Quick tests for clinical settings

There are a number of short, easy to administer assessment tools that can be used as screening tools in clinical settings. These tools don’t always detect low health literacy, but their simplicity and speed makes them suitable for use in many health settings. Before deciding to administer a test, be clear about your aim, what value the test will have for the consumer or the clinical interaction, and make sure the potential value will outweigh any potential harms.

Newest Vital Sign

This validated tool is widely used in the United States.  It is a quick and accurate screening test for general literacy, numeracy, and comprehension skills applied to health information, and is designed to be used in health care settings. It takes about three minutes to administer and is based on an ice cream container nutrition label. Patients read the label and an assessor asks six questions about how the patient would use the information on the label. A scoring sheet, with the correct answers, is used to record the responses. Fewer than four correct answers suggests the possibility of low health literacy. The Newest Vital Sign tool is available at no cost.

Brief Health Literacy Screening Tool – BRIEF

This is a four question screening test that is effective at screening for people with below basic health literacy skills (grade 5 or below). It is less effective for identifying patients with higher levels of health literacy skills [viii]. The three questions are:

1. How often do you have somebody help you read hospital materials?
2. How confident are you filling out medical forms by yourself?
3. How often do you have problems learning about your medical condition because of difficulty understanding written information?
4. How often do you have a problem understanding what is told to you about your medical condition?

One study found that the BRIEF Tool is no more effective at identifying people with low health literacy than asking the single question: “How confident are you filling out medical forms by yourself?”[ix].

Single Item Literacy Screener

The Single Item Literacy Screener (SILS) reliably identifies patients with low health literacy[x]. This tool asks: “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from you doctor or pharmacist?” Responses are rated from “1” (never) to “5” (always). Responses above 2 identify patients who may need health literacy support.

Other Methods

Another way to screen for possible low health literacy is to ask patients to read their prescription bottles and then explain how to take the medication.

Universal Precautions Approach

Rather than assess the health literacy of individual patients, it is best to adopt a universal precautions approach. This means assuming that all patients may experience difficulty understanding, and:

• finding out what patients already know,
• sharing clear information with patients,
• helping patients build their understanding of how their body works, their health issues and associated treatment options, and
• how to navigate the health system.

You can find out more about on our Universal Precautions approach page.

References:

[i] Dodson S, Good S, Osborne RH. Health literacy toolkit for low- and middle-income countries: a series of information sheets to empower communities and strengthen health systems. New Delhi: World Health Organization, Regional Office for South-East Asia, 2015.

[ii] Haun JN, Valerio MA, McCormack LA, Sørensen K, Paasche-Orlow MK. Health literacy measurement: an inventory and descriptive summary of 51 instruments. J Health Commun. 2014;19 Suppl 2:302-33. doi: 10.1080/10810730.2014.936571. PMID: 25315600.

[iii] Osborne R, Batterham R, Elsworth G, Hawkins M, Buchbinder R. The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC Public Health 2013;13(1):658.

[iv] National Health Survey: Health Literacy, 2018. Australian Bureau of Statistics. https://www.abs.gov.au/statistics/health/health-conditions-and-risks/national-health-survey-health-literacy/latest-release#about-the-health-literacy-survey

[v] Easton, P., Entwistle, V.A. & Williams, B. How the stigma of low literacy can impair patient-professional spoken interactions and affect health: insights from a qualitative investigation. BMC Health Serv Res 13, 319 (2013). https://doi.org/10.1186/1472-6963-13-319

[vi] Paasche-Orlow MK, Wolf MS: Evidence does not support clinical screening of literacy. J Gen Intern Med. 2007, 23 (1): 100-102.

[vii] Wolf MS, Williams MV, Parker RM, Parikh NS, Nowlan AW, Baker DW: Patients’ shame and attitudes toward discussing the results of literacy screening. J Health Commun. 2007, 12: 721-732. 10.1080/10810730701672173

[viii] Chew, L. D., Bradley, K. A., & Boyko, E. J. (2004). Brief questions to identify patients with inadequate health literacy. Family Medicine, 36(8), 588-594

[ix] Wallace, L. S., Rogers, E. S., Roskos, S. E., Holiday, D. B., & Weiss, B. D. (2006). Screening items to identify patients with limited health literacy skills. Journal of General Internal Medicine, 21, 874-877.

[x] Morris, N. S., MacLean, C. D., Chew, L. D., & Littenberg, B. (2006). The single item literacy screener: Evaluation of a brief instrument to identify limited reading ability. BMC Family Practice, 7, 21. Available from http://biomedcentral.com/l47l-2296-7-21