Measuring health literacy

Classification of health literacy skills

There are many simple (and sometimes more comprehensive) tools to measure health literacy. Health literacy for an individual is often classified as:

  • poor or inadequate: causing the patient and society as well, many problems;
  • limited/marginal: causing the patient avoidable problems;
  • sufficient or adequate: main patient’s needs are met;
  • excellent: high and indicating competency of critical health literacy in particular. This category does not exist in many measurement instruments.

The boundaries between categories are not rigid, and they are best understood relatively. The picture is more complex than simply classifying an individual into just one of these categories because some people have excellent health literacy in one area of their life (managing diabetes for instance) but poor health literacy in another area (e.g., difficulty in taking antibiotics correctly). The ideal is for everyone to have adequate or excellent health literacy in all health areas, but this is unlikely in reality. With regard to policy and intervention planning, it may be most cost effective to focus resources on those with poor or low health literacy.

Commonly used questions for measuring health literacy

Poor health literacy can be a very hidden problem. Therefore, recognising people with low health literacy is difficult. Using a questionnaire to identify someones health literacy level may help. The table below lists a selection of commonly used questions and test formats (instruments) to identify in which category of health literacy individuals fall. This list is not comprehensive. The choice of the most appropriate questions or formal test depends on the patient and on the specific information needs of a (research) program. Although most of these documents were originally developed in English, many have been translated or adapted and are now available in other languages and applicable in diverse cultures. In addition, there are survey instruments to assess health literacy in specific health areas (such as managing type 2 diabetes).


Simple questions
“How confident are you filling out medical forms by yourself?”The most effective of three questions in Chew et al 2004.
“How often do you have someone help you read hospital


Other single questions validated in Chew et al, for measuring health literacy.
“How often do you have problems learning about your medical condition because of difficulty understanding written information?”
Survey Tests (Instruments) Comments
REALMThe most established of early health literacy instruments. Patients are asked to read medical-related words aloud. 12-60 words or word phrases are given to the patient to read.Scores are calculated when the patient mispronounces a word.
HLS-EULong version: 47 statements with agreement to be indicated by interviewee on a Likert scale. Reduced length versions are 12-35 questions.
TOFHLAA fill-in-the-blank format questionaire, where patients are given a list of the possible words for each of 50 blank spaces. They are required to choose the corrrect word in each context (only one correct answer).
SAHLSA50 questions where the patient must choose which words are most closely related, such as ‘menopause’ and ‘ladies’. (Spanish language)
NVSPatients are asked to read a food label and answer six questions about ingredients, portion size, calories and carbohydrate or fat content. Available in North American and European versions.
Health Literacy Questionnaire (HLQ)The objectives of this questionnaire are to diagnose health literacy needs across individuals and organisations by utilizing perspectives from the general population, patients, practitioners and policymakers.



Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. health 2004; 11: 12.

Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Family medicine 1993; 25(6): 391-5.

HLS-EU Consortium. Comparative Report of Health Literacy in Eight EU Member States. The European Health Literacy Survey HLS-EU, 2012.

Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults. Journal of general internal medicine 1995; 10(10): 537-41.

Lee SYD, Bender DE, Ruiz RE, Cho YI. Development of an Easy‐to‐Use Spanish Health Literacy Test. Health Services Research 2006; 41(4p1): 1392-412.

Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the newest vital sign. The Annals of Family Medicine 2005; 3(6): 514-22.

Osborne, R. H., Batterham, R. W., Elsworth, G. R., Hawkins, M., & Buchbinder, R. (2013). The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC public health, 13 (1), 658.