Assessing Health Literacy

Numerous well-validated instruments are available for assessing patient health literacy, however a ‘universal precautions’ approach of presenting health information to everyone in a clear, easily understood manner is recommended for all patients. It is important to provide a shame-free environment with patients with low health literacy, so interacting with everyone as if they are at risk of not understanding health information is the best approach. The U.S. Department of Health & Human Services Agency for Healthcare Research and Quality (AHRQ) recommends a Universal Precautions approach. These precautions are aimed at:

  • Simplifying communication with and confirming comprehension for all patients, so that the risk of miscommunication is minimized.
  • Making the office environment and health care system easier to navigate. 
  • Supporting patients’ efforts to improve their health.

While some instruments are well suited for research, others are useful in a clinical setting, as they can be rapidly administered. Listed below are several of the assessments most commonly applied by researchers and clinical personnel in gauging patient-participant health literacy levels.

Health Literacy Tool Shed

The Health Literacy Tool Shed is an online database of over 150 health literacy measures in many languages. To be included in the database, measures must have been validated and published in peer-reviewed journals. Each entry contains characteristics of the measure, including approximate administration time and language of the validated version.

Select clinical assessments:

NVS (Newest Vital Sign)

The NVS consists of a nutrition label with 6 accompanying questions to assess literacy. It takes approximately 3 minutes to administer. It allows healthcare providers to make a quick assessment of patients’ literacy level, which then allows them to adapt communication to achieve better outcomes. It assesses literacy and numeracy, and is available in both English and Spanish versions.

Obtain a copy in English or Spanish from Pfizer .


SILS (Single Item Literacy Screener) 

The SILS is a single item instrument designed to identify patients who need help with reading health-related information. The instrument asks one question “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” with possible responses ranging from “1” (never) to “5” (always). The authors identified the cut-off point as “2” in order to capture all patients potentially in need of assistance. 

To obtain a copy, contact the corresponding author.

Select research assessments:

REALM (Rapid Assessment of Adult Literacy in Medicine) 

The REALM is a screening tool designed to measure adults’ ability to read common medical words or lay terms that correspond to anatomy or illnesses. As a word recognition test, the REALM does not assess comprehension. However, it is highly correlated with other tests of comprehension. It takes approximately 3 minutes to administer and score. 

To obtain a copy: Contact Dr. Terry C. Davis at 


REALM-R (Rapid Assessment of Adult Literacy in Medicine-Revised) 

The REALM-R is a shortened version of the REALM, which is used to help identify literacy levels of adult patients. It consists of 8 items, and is used to measure how well individuals can read words they will encounter in a medical setting. 

To obtain a copy: Contact Dr. Terry C. Davis at 


SAHLSA (Short Assessment of Health Literacy for Spanish-speaking Adults) 

The SAHLSA consists of a word-recognition section, designed after the REALM, as well as a comprehension test that employs multiple choice questions. It was designed to assess the health literacy for adults whose native language is Spanish. 

To obtain a copy: Contact Dr. Shoou-Yih D. Lee at 


TOFHLA (Test of Functional Health Literacy in Adults) 

The complete TOFHLA test consists of reading comprehension and numeracy sections. The former is composed of 50 questions, the latter of 17 items. The entire test usually takes up to 22 minutes to administer. The reading passages and numeracy question are taken from common medical scenarios. The s-TOFHLA is a truncated version that only uses questions from the reading comprehension subsection of the full test. There are 36 items that are administered in 7 minutes. The scoring categorizes respondents into inadequate, marginal or adequate levels of health literacy. 

Obtain a copy of the TOFHLA (Test of Functional Health Literacy in Adults) from the Health Literacy Tool Shed

Last modified: 02/01/21