Measurement Variation Across Health Literacy Assessments: Implications for Assessment Selection in Research and Practice

Figures & data

Table 1. Comparison of characteristics of the S-TOFHLA, REALM, and BRIEF

Variable	S-TOFHLA*	REALM*	BRIEF*
Description	Reading comprehension	Medical word recognition and pronunciation test	Self-report of health literacy skills
Time to administer	7 minutes	2–7 minutes	1–2 minutes
Score range ^†	0–36	0–66	4–20
Scoring	0–16 = inadequate 17–22 = marginal 23–36 = adequate	0–44 = limited (0–6th-grade level) 45–60 = marginal (7th–8th-grade level) 61–66 = adequate (9th-grade and above)	4–12 = inadequate literacy 13–16 = marginal literacy 17–20 = adequate literacy
Advantages	Available in Spanish	Can be quick, uses medical terminology	Quick and easy to administer
Limitations	• Has to be administered and timed • Requires materials	• Has to be administered • Requires materials	Self-report, not performance based
Correlations ^‡ (r value)	• REALM 0.61 • BRIEF 0.42	• S-TOFHLA 0.61 • BRIEF 0.40	• S-TOFHLA 0.42 • REALM 0.40

Table 2. Demographic distribution for descriptive variables

Demographic variable	Value
Age, years
Range	23–89
Average (SD)	61.5 (11.9)
Gender, no. (%)
Male	356 (94.2)
Female	19 (5.0)
Not reported	3 (0.8)
Ethnicity, no. (%)
Caucasian/White (Nonminority)	278 (73.5)
African American/Black	69 (18.3)
Hispanic/Latino	12 (3.2)
Native American/Alaskan Native	12 (3.2)
Hawaiian, Pacific Islander	0 (0.0)
Asian American	1 (0.3)
Other	3 (0.8)
Not reported	3 (0.8)
Education, no. (%)
Less than high school	71 (18.9)
High school diploma/GED	98 (25.9)
Some college	126 (33.3)
College degree	80 (21.2)
Trade school	1 (0.3)
Not reported	2 (0.5)
English first language, no. (%)
Yes	366 (97.0)
No	10 (2.6)
Not reported	2 (0.5)
Self-reported reading level, no. (%)
Excellent	95 (25.1)
Very good	113 (29.9)
Good	113 (29.9)
Fair	42 (11.1)
Poor	13 (3.4)
Not reported	2 (0.5)
Home ownership (Income Proxy), no. (%)
Rent	80 (21.2)
Own	290 (76.7)
Not reported	8 (2.1)
Employment status, no. (%)
Employed	366 (96.8)
Unemployed	10 (2.6)
Not reported	2 (0.5)
Retirement status, no. (%)
Retired	147 (38.9)
Not retired	229 (60.6)
Not reported	2 (0.5)
Functional status, no. (%)
Disability	91 (24.0)
No disability	285 (75.4)
Not reported	2 (0.5)
Diabetes, no. (%)
Yes	132 (34.9)
No	244 (64.6)
Not reported/don't know	2 (0.5)
High blood pressure, no. (%)
Yes	242 (64.0)
No	133 (35.2)
Not reported/don't know	3 (0.8)
Stroke, no. (%)
Yes	41 (10.8)
No	335 (88.6)
Not reported/don't know	2 (0.5)

Figure 1 Participants' health literacy level as indicated by the S-TOFHLA, REALM, and BRIEF.

Table 3. Univariate results for demographical variables associated with health literacy level instrument by the S-TOFHLA, REALM, and BRIEF

	S-TOFHLA (n = 378)			REALM (n = 378)			BRIEF (n = 378)
Variable	Inadequate/marginal (n = 63)	Adequate (n = 315)	p	Limited/marginal (n = 138)	Adequate (n = 240)	p	Inadequate/marginal (n = 214)	Adequate (n = 164)	p
Age (years)*
59 or younger	12 (7.6)	145 (92.4)	.001	53 (33.8)	104 (66.2)	.848	82 (52.2)	75 (47.8)	.478
60–69	16 (13.0)	107 (87.0)		46 (37.4)	77 (62.6)		73 (59.3)	50 (40.7)
70–79	25 (35.7)	45 (64.3)		27 (38.6)	43 (61.4)		42 (60.0)	28 (40.4)
80 or older	14 (56.0)	11 (44.0)		10 (40.0)	15 (60.0)		16 (64.0)	9 (36.0)
Gender
Male	64 (18.0)	292 (82.0)	.154	133 (37.4)	223 (62.6)	.057	206 (57.9)	150 (42.1)	.024
Female	1 (5.3)	18 (94.7)		3 (15.8)	16 (84.2)		6 (31.6)	13 (68.4)
Ethnicity
Minority	23 (23.5)	75 (76.5)	.073	49 (50.0)	49 (50.0)	.001	56 (57.1)	42 (42.9)	.958
Nonminority	43 (15.5)	235 (84.5)		87 (31.3)	191 (68.7)		158 (56.8)	120 (43.2)
Education
High school or more	22 (10.7)	184 (89.3)	.001	93 (54.7)	77 (45.3)	.001	117 (68.8)	53 (31.2)	.001
Less than high school	45 (26.5)	125 (73.5)		43 (20.9)	163 (79.1)		96 (46.6)	110 (53.4)
Self-reported reading level
Fair/poor	25 (45.5)	30 (54.5)	.001	41 (74.5)	14 (25.5)	.001	51 (92.7)	4 (7.3)	.001
Good/excellent	42 (13.0)	281 (87.0)		97 (30.0)	226 (70.0)		163 (50.5)	160 (49.5)
Home ownership
Rent home	11 (13.8)	69 (86.2)	.317	31 (38.8)	49 (61.2)	.620	47 (58.8)	33 (41.2)	.623
Own home	54 (18.6)	237 (81.4)		104 (35.7)	187 (64.3)		162 (55.7)	129 (44.3)
Employment
Unemployed	0 (0.0)	10 (100.0)	.136	5 (50.0)	5 (50.0)	.377	7 (70.0)	3 (30.0)	.388
Employed	67 (18.3)	299 (81.7)		133 (36.3)	233 (63.7)		206 (56.3)	160 (43.7)
Retirement
Retired	37 (25.2)	110 (74.8)	.003	50 (43.0)	97 (66.0)	.386	78 (53.1)	69 (46.9)	.261
Not Retired	30 (13.1)	199 (86.9)		88 (38.4)	141 (61.6)		135 (59.0)	94 (41.0)
Functional status
Disability	71 (78.0)	20 (22.0)	.234	40 (44.0)	51 (56.0)	.099	63 (69.2)	28 (30.8)	.005
No disability	47 (16.5)	238 (83.5)		98 (34.4)	187 (65.6)		150 (52.6)	135 (47.4)
Health status
Diabetes	20 (15.2)	112 (84.8)	.368	44 (33.3)	88 (66.7)	.358	82 (62.1)	50 (37.9)	.115
No diabetes	46 (18.9)	198 (81.1)		93 (38.1)	151 (61.9)		131 (53.7)	113 (46.3)
High blood pressure	50 (20.7)	192 (79.3)	.036	95 (39.3)	147 (60.7)	.183	149 (61.6)	93 (38.4)	.008
No high blood pressure	16 (12.0)	117 (88.0)		43 (32.3)	90 (67.7)		63 (47.4)	70 (52.6)
Stroke	12 (29.3)	29 (70.7)	.037	16 (39.0)	25 (61.0)	.715	28 (68.3)	13 (31.7)	.111
No stroke	54 (16.1)	281 (83.9)		121 (36.1)	214 (63.9)		185 (55.2)	150 (44.8)

Table 4. Adjusted logistic regression of sociodemographic and health status variables associated with low health literacy

	S-TOFHLA		REALM		BRIEF
	Odds ratio	Confidence interval	Odds ratio	Confidence interval	Odds ratio	Confidence interval
Age, per 10 years	1.12	(1.07, 1.16)*	1.01	(0.99, 1.04)	1.02	(1.00, 1.05)*
Male	0.92	(0.10, 8.30)	1.80	(0.49, 6.67)	2.22	(0.75, 6.53)
Minority, non-White	2.47	(1.17, 5.24)*	2.66	(1.51, 4.70)*	0.87	(0.51, 1.50)
High school education or less	1.83	(0.94, 3.56)	3.91	(2.38, 6.43)*	1.83	(1.15, 2.92)*
Self-reported reading level, poor	4.37	(2.00, 9.54)*	5.37	(2.53, 11.40)*	11.43	(3.40, 38.39)*
Retired, yes	1.28	(0.47, 3.47)	0.76	(0.37, 1.53)	0.54	(0.28, 1.04)
Disability, yes	2.56	(0.96, 6.85)	0.98	(0.50, 1.91)	1.24	(0.66, 2.34)
Diabetes, yes	0.57	(0.28, 1.16)	0.60	(0.35, 1.02)	1.15	(0.70, 1.87)
High blood pressure, yes	1.10	(0.52, 2.36)	1.16	(0.67, 2.00)	1.28	(0.78, 2.11)
Stroke, yes	1.68	(0.71, 3.98)	0.80	(0.36, 1.80)	1.38	(0.63, 3.00)

Table

S-TOFHLA	REALM	BRIEF
Assesses reading and comprehension	Assesses medical vocabulary using word recognition and pronunciation	Assesses reading and verbal comprehension, need for assistance, and confidence filling out medical forms
7 minutes to administer	2–7 minutes to administer	1–2 minutes to administer
Performance-based measure	Performance-based measure	Not performance-based, self-report bias potential
Identified as reference standard in the literature	Identified as reference standard in the literature	Individual items assess different skill components and can be evaluated individually
Context related to medical instruction comprehension and completing medical forms	Appropriate when assessing verbal health communication skills	Self-report avoids performance pressure and embarrassment
Requires materials, timing, and formal administration	Requires materials and formal administration	Does not require materials or formal administration
	Condition specific versions available	Can be administered by phone

Haun , J. , Noland Dodd , V. J. , Graham-Pole , J. , Rienzo , B. , & Donaldson , P. (2009). Testing a health literacy screening tool: Implications for utilization of a BRIEF health literacy indicator. Federal Practitioner , 26, 24–31.

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