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Table 2 Main instrument characteristics categorized into objective, subjective and mixed measurement

From: The evolution of health literacy assessment tools: a systematic review

Instrument*

Author

Design and scope

Sample

Reliability

Validity sensitivity/Specifity

Instrument availability

instruments with an objecitve measurement approach (N = 5)

    

METER

Rawson et al. 2009 [38]

40 medical words and 40 non-medical words Scoring: Low literacy (0–20); Marginal literacy (21–34) Functional literacy (35–40)

154 participants; mean age: 62.7 years (range: 29–88); 76.5% male; 92.6% white

Internal consistency: Cr. α = 0.93

REALM r = 0.74; 75% correct and 8% false positives identification

Available

Talking Touchscreen

Yost et al. 2009 [44]

Adoption of items from the NALS/NAAL framework and application to health-related materials; development of 138 items: 58 prose, 39 document, 41 quantitative Scoring: Not described

97 English participants, 134 Spanish participant; 65% female English, 74.6% female Spanish;

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Partly available

CHC Test

Steckelberg et al. 2009 [42]

72 items; categories: Medical concepts, literature, statistics, design of experiments and sampling Scoring: not described

Phase 2: 322 trained and non-trained secondary school and university students; Phase 3: 107 grade 11 secondary school classes students

Phase 2: Reliability Rasch model = 0.88 Phase 3: Reliability Rasch model = 0.91

Effect size: Cohen’s d = 4.33

Not available

SAHL-S&E

Lee et al. 2010 [40]

32 items, reading test in Spanish and English Scoring: Cutoff point for low HL: ≤14

202 English-speaking and 201 Spanish-speaking participants aged 18–80 years

SAHL-S = 0.80 SAHL-E = 0.89

SAHL-S and SAHLSA: r = 0.88 SAHL-S and TOFHLA: r = 0.62 SAHL-E and REALM: r = 0.94 SAHL-E and TOFHLA: r = 0.68

Available

Health and financial literacy

James et al. 2012 [41]

9 questions in health literacy, 23 questions on financial literacy Scoring: Percentage correct out of total items (range 0–1)

525 participants mean age 82.6 years 76% female; 91.2% white

Internal consistency: Cr. α = 0.77

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Available

instruments with an subjecitve measurement approach (N = 5)

    

MHLS-50

Tsai et al. 2011 [48]

63 items with four sections: health materials, outpatient dialogues, prescription labels, health-related written documents Scoring: (0–30) inadequate health literacy; (31–42) marginal health literacy; (43–50) adequate health literacy

323 individuals; mean age = 47 years

Internal consistency: Cr. α = 0.95; Split half reliability = 0.95

Years of schooling r = 0.72 Reading habit r = 0.34 Health knowledge r = 0.55 Reading assistance r = -0.52

Not available

HLS-CH

Wang et al. 2012 [45]

Questionnaire of 158 items; 127 questions on 30 competencies for health Scoring: not described

1255 participants: (652 German-speaking, 303 French-speaking, 300 Italian-speaking) age +15 years

Internal consistency: Cr. α for each factor: Information and decision making α = 0.72, Cognitive and inter-personal skills α =0.81, ICT skills α = 0.77; Health activation α = 0.60

Correlations: Correlations: Cognitive and interpersonal skills and ICT skills factors = 0.50; Information and decision- making and ICT skills factors = 0.27

Not available

AAHLS

Chinn et al. 2012 [47]

4 items functional health literacy, 3 items on communicative health literacy, 4 items on critical health literacy, 3 empowerment items Scoring: not described

146 participants: mean age 38 years, 78% female; 56% Asian, 3% Black, 35% White

Internal consistency: Total items Cr. α = 0.75; Functional items Cr. α = 0.82; Communicative items Cr. α = 0.69; Critical items Cr. α = 0.42

Correlations: Functional & communicative items r = 0.393; Functional & critical items r = 0.59; Communicative & critical items r = 0.186

Partly available

HELMS

Jordan et al. 2013 [16]

8 domains with 29 items; capacity to seek, understand and use health information within the health care setting Scoring: not described

15 participants: 2 aged 40–49, 1 aged 50–59, 6 aged 60–69, 5 aged 70–79, and 1 aged 80+ years; 80% female

Test-retest: ICC = 0.73-0.96 (5 domains ICC > 0.90); Understanding health information: reliability = 0.73; Cr. α >0.82 for all factors

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Not available

MAHL

Massey et al. 2013 [37]

Questionnaire, sixth grade reading level; adaption of items from YAHCS, HINTS and eHEALS Scoring: not described

1208 adolescents: mean age 14.8 years (range 13–17); 62.4% female; 22.1% white, 13.2% black, 33.7% Hispanic, 7.9% Asian

Internal consistency: all but one domain had Cr. α >0.7; overall = 0.834; lowest = 0.64

Consistency: average inter-item correlations (0.33 to 0.66); discriminability: item-total correlations (0.39 to 0.74)

available

instruments with an mixed measurement approach (N = 7)

 

HLSI

McCormack et al. 2010 [36]

25 item instrument; skills set areas: print, oral, and Internet-based information seeking Scoring: ≥82: Proficient literacy; 70–81: Basic literacy; <70: Below basic literacy

889 participants; 22% 18–29 years, 25% 30–44 years, 27% 45–59 years, 26% 65+ years; 52% female; 64% white, 13% black, 17% Hispanic

Internal consistency: Cr. α =0.86

S-TOFHLA and HSLI correlation = 0.47; Sensitivity = 0.71; Specificity = 0.65

Available

Canadian exploratory study

Begoray et al. 2012 [52]

Qualitative open-ended questions; Questions on 2 reading passages Scoring: not described

229 participants; mean age 76 years (range 60–96); 65% female; 64%

Internal consistency: Cr. α =0.852; removal of any of the measures form the analysis reduced Cr. α down to 0.832

Reading passages scores & correlated REALM scores: spearman´s rho = 0.212; sum scale scores & English as first language rho = 0.228; sum scale scores & age rho = -0.176; education rho = 0.175 household income rho = 0.162

Partly available

HL of Canadian high school students

Wu et al. 2010 [53]

11 passages and 47items (30 understand and 17 evaluate items) Scoring: not described

275 students: 8% male; 69.1% speak a language other than English at home

Internal consistency: understand: Cr. α = 0.88; evaluate: Cr. α = 0.82; overall: Cr. α = 0.92

bivariate correlations: overall & age r = -0.173overall & gender r = -0.182 overall & GPA: r = 0.475 understand & evaluate: r = 0.80 understand & overall r = 0.97 evaluate & overall r = 0.92

Not available

SLS and SNS

McNaughton et al. 2011 [56]

SLS: 3 questions, each with a five-point likert response scale SNS: 8 written questions, each on a six-point likert response scale Scoring: not described

207 patients mean age 46 years (32–59) 55% male

Internal consistency: SLS: Cr. α = 0.74; SNS: Cr. α = 0.82

spearman´s rank: SLS and STOFHLA = 0.33 SLS and REALM = 0.26 SLS and WRAT4 = 0.26 SLS and educational = 0.25 AU ROC: SLS and STOFHLA AUC = 0.74 SLS and REALM AUC = 0.72

Not available

SDPI-HH HL

Brega et al. 2012 [59]

The questionnaire assesses 4 types of knowledge: general diabetes, insulin use, cholesterol, and blood pressure knowledge Scoring: Scores on each test reflect the percentage of items answered correctly

3,033 participants 5.9% aged 18–34, 15.5% aged 35–44, 28.2% aged 45–54, 30.4% aged 55–64, 20% aged 65+ years; 66.4% female

Internal consistency: PL items Cr. α = 0.67

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Available

HLSI-SF

Bann et al. 2012 [50]

10 item instrument that measures print literay, numeracy, oral literacy, navigation through the internet Scoring: Number of items answered correctly

889 participants: 22% 18–29 years, 25% 30–44 years, 27% 45–59 years, 26% 60+ years; 52% female; 64% white, 13% black, 17% Hispanic

Internal consistency: Cr. α = 0.70

Correlation with S-TOFHLA r = 0.36

Available

HLS-EU

HLS-EU Consortium 2012 [8]

47 items; in three domains: health care, disease prevention, health promotion Scoring: Metric between 0-50

8102 participants from Germany, Greece, Bulgaria, Ireland, Austria, Spain, Netherlands, Poland

Internal consistency Cr. α: Gen HL = 0.97 HC HL = 0.91 DP HL = 0.91 HP HL = 0.92

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Partly available

  1. *MHLS-50 = Mandarin Health Literacy Scale; HLS-CH = Swiss Health Literacy Survey; AAHLS = All Aspects of Health Literacy Scale; HeLMS = Health Literacy Management Scale.
  2. *MAHL = Multidimensional measure of adolescent health literacy; HLSI = skill-based health literacy instrument.
  3. *SAHL-S&E = Short assessment of health literacy – Spanish and English; SDPI-HH-HL: Special Diabetes Program for Indians Healthy Heart Health Literacy; HLSI-SF = Health Literacy Skills Instruments – Short Form; HLS –EU = Health Literacy Survey for the European Union.