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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; / / 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 / 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 / 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 / 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 / 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.