Health literacy assessment tools: a comparative review
DOI:
https://doi.org/10.14748/4ne3r911Keywords:
health literacy, patient, Assessment Tools, measurement health literacy, scaleAbstract
Purpose: This study aims to provide a comprehensive analysis of the main standardized instruments used to assess health literacy, highlighting their key characteristics through a content analysis and evaluating their relevance across various contexts.
Methods: A documentary research method was used to collect and analyze scientific information from the electronic databases Scopus, Web of Science, and Google Scholar in two steps. In the first phase, relevant publications related to health literacy measurement were identified and reviewed. Eight studies that validate or standardize different health literacy assessment scales were selected for in-depth analysis. In the second phase, a targeted literature search was conducted using the names of the identified scales as keywords. PRISMA diagram was accomplished.
Results: The study conducted a comparative analysis of the following instruments: REALM, TOFHLA, NVS, MART, DAHL, HLQ, AAHLS, and HLS-EU-Q. The findings indicate that the applicability of each instrument varies according to the demographic and contextual features of the population being assessed. The most frequently used instrument is the HLS-EU-Q, which has been validated in several European countries. NVS and MART are considered suitable for use in clinical settings. The DAHL instrument is appropriate for national-level surveys, while TOFHLA is widely used to assess functional health literacy.
Conclusions: Several standardized tools are available for the assessment of health literacy across diverse populations and contexts. The SWOT analysis conducted in this study is intended to support future research in selecting the most appropriate scientific method for health literacy evaluation by presenting comparative information on eight of the most commonly used questionnaires.
References
[1] Dumenci L, Matsuyama RK, Kuhn L, Perera RA, Siminoff LA. On the Validity of the Rapid Estimate of Adult Literacy in Medicine (REALM) Scale as a Measure of Health Literacy. Commun Methods Meas 2013;7:134–43. https://doi.org/10.1080/19312458.2013.789839. DOI: https://doi.org/10.1080/19312458.2013.789839
[2] Ratzan S, Apfel F. NCD health literacy--what can hospitals do? World Hospitals and Health Services : The Official Journal of the International Hospital Federation 2011;47:8–12.
[3] Nielsen-Bohlman L, Panzer AM, Kindig DA. What Is Health Literacy? Health Literacy: A Prescription to End Confusion, Literacy, National Academies Press (US); 2004.
[4] Health Literacy | National Institutes of Health (NIH) 2025. https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/health-literacy (accessed September 12, 2025
[5] Sørensen K, Van den Broucke S, Fullam J, Doyle G, Pelikan J, Slonska Z, Brand H, (HLS-EU) Consortium Health Literacy Project European. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 2012;12:80. https://doi.org/10.1186/1471-2458-12-80. DOI: https://doi.org/10.1186/1471-2458-12-80
[6] Singh GK, Lee H, Kim LH, Daus GP. Promoting Health Literacy as an Important Initiative in Reducing Health Disparities and Advancing Health Equity. Int J Transl Med Res Public Health 2024;8. https://doi.org/10.25259/IJTMRPH_58_2024. DOI: https://doi.org/10.25259/IJTMRPH_58_2024
[7] Howard DH, Sentell T, Gazmararian JA. Impact of health literacy on socioeconomic and racial differences in health in an elderly population. J GEN INTERN MED 2006;21:857–61. https://doi.org/10.1111/j.1525-1497.2006.00530.x. DOI: https://doi.org/10.1111/j.1525-1497.2006.00530.x
[8] Shah S. Health literacy and how to communicate effectively with patients to elicit a long-term behavioural change. A Prescription for Healthy Living: A Guide to Lifestyle Medicine, 2021, p. 47–59. https://doi.org/10.1016/B978-0-12-821573-9.00004-7. DOI: https://doi.org/10.1016/B978-0-12-821573-9.00004-7
[9] Ghalavand H, Nabiolahi A, Panahi S. Health literacy and motivation to change health behavior among cardiovascular patients. BMC Cardiovascular Disorders 2025;25:479. https://doi.org/10.1186/s12872-025-04936-w. DOI: https://doi.org/10.1186/s12872-025-04936-w
[10] Matović A, Arsenijević O. INTANGIBLE CULTURAL HERITAGE AS AN IMPORTANT ECONOMIC FACTOR IN SOCIETAL DEVELOPMENT. SCIENCE International Journal 2025;4:13–7.
[11] Tsvetkova A., Todorova A., Petkova V. THE ROLE OF PHARMACIST AS AN ADVISOR ON RESPONSIBLE SELF-MEDICATION: A SURVEY. 1 2014;3.
[12] Getova V, Getov I. Medicine packaging pictograms in the context of the electronic product information (ePI) proposal. Eur J Hosp Pharm 2022;29:121–2. https://doi.org/10.1136/ejhpharm-2021-002960. DOI: https://doi.org/10.1136/ejhpharm-2021-002960
[13] Ivanova M, Todorova A, Georgieva L, Pesheva M. IMPACT OF INFODEMIA ON THE ROLE OF THE PHARMACIST AS A CONSULTANT IN THE CONDITION OF COVID-19. Academic Journal Management and Education, 2021;Vol. 18:47–53
[14] Petrova-Geretto E, Yanakieva A, Vodenicharova A. HEALTH LITERACY: A CALL FOR ACTION FOR A JUST AND EGALITARIAN SOCIETY. SCIENCE International Journal 2023;2:37–40. https://doi.org/10.35120/sciencej020137d DOI: https://doi.org/10.35120/sciencej020137d
[15] Mackert M, Champlin S, Su Z, Guadagno M. The Many Health Literacies: Advancing Research or Fragmentation? Health Communication 2015;30:1161–5. https://doi.org/10.1080/10410236.2015.1037422. DOI: https://doi.org/10.1080/10410236.2015.1037422
[16] World Health Organization. Framework and standards for country health information systems, 2nd ed 2023. https://www.who.int/publications/i/item/9789241595940 (accessed February 12, 2025).
[17] Olayiwola JN, Anteyi E, Obanua F, Rollins A, Baustien LB, Smith T, Franklin SM, Magaña C. To Advance Health Equity, Make Health Literacy A Priority At The Organizational Level. Health Affairs Forefront n.d. https://doi.org/10.1377/forefront.20240718.801922. DOI: https://doi.org/10.1377/forefront.20240718.801922
[18] Petrova G, Todorova A, Georgiev T, Petkova-Gueorguieva E, Mihaylova A, Peikova L, Balkanski S, Gueorguiev S. Assessment of patients’ awareness on drugs use and adherence to drug therapy as an element of Medication Review service. Pharmacia 2023;70:595–601. https://doi.org/10.3897/pharmacia.70.e109838. DOI: https://doi.org/10.3897/pharmacia.70.e109838
[19] Gürel E, Tat M. SWOT Analysis: A Theoretical Review. Journal of International Social Research 2017;10:994–1006. https://doi.org/10.17719/jisr.2017.1832. DOI: https://doi.org/10.17719/jisr.2017.1832
[20] Blayney DW. Strengths, Weaknesses, Opportunities, and Threats. J Oncol Pract 2008;4:53. https://doi.org/10.1200/JOP.0820501. DOI: https://doi.org/10.1200/JOP.0820501
[21] Sarsby A. A Useful Guide to SWOT Analysis n.d.
[22] Davis TC, Long SW, Jackson RH, Mayeaux EJ, George RB, Murphy PW, Crouch MA. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med 1993;25:391–5.
[23] Arozullah AM, Yarnold PR, Bennett CL, Soltysik RC, Wolf MS, Ferreira RM, Lee S-YD, Costello S, Shakir A, Denwood C, Bryant FB, Davis T. Development and validation of a short-form, rapid estimate of adult literacy in medicine. Med Care 2007;45:1026–33. https://doi.org/10.1097/MLR.0b013e3180616c1b. DOI: https://doi.org/10.1097/MLR.0b013e3180616c1b
[24] Bass PF, Wilson JF, Griffith CH. A Shortened Instrument for Literacy Screening. J Gen Intern Med 2003;18:1036–8. https://doi.org/10.1111/j.1525-1497.2003.10651.x. DOI: https://doi.org/10.1111/j.1525-1497.2003.10651.x
[25] Parker RM, Baker DW, Williams MV, Nurss JR. The test of functional health literacy in adults: a new instrument for measuring patients’ literacy skills. J Gen Intern Med 1995;10:537–41. https://doi.org/10.1007/BF02640361. DOI: https://doi.org/10.1007/BF02640361
[26] Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Education and Counseling 1999;38:33–42. https://doi.org/10.1016/S0738-3991(98)00116-5. DOI: https://doi.org/10.1016/S0738-3991(98)00116-5
[27] Weiss BD, Mays MZ, Martz W, Castro KM, DeWalt DA, Pignone MP, Mockbee J, Hale FA. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med 2005;3:514–22. https://doi.org/10.1370/afm.405. DOI: https://doi.org/10.1037/t23417-000
[28] Hanson-Divers EC. Developing a medical achievement reading test to evaluate patient literacy skills: a preliminary study. J Health Care Poor Underserved 1997;8:56–69. https://doi.org/10.1353/hpu.2010.0304. DOI: https://doi.org/10.1353/hpu.2010.0304
[29] Hanchate AD, Ash AS, Gazmararian JA, Wolf MS, Paasche-Orlow MK. The Demographic Assessment for Health Literacy (DAHL): a new tool for estimating associations between health literacy and outcomes in national surveys. J Gen Intern Med 2008;23:1561–6. https://doi.org/10.1007/s11606-008-0699-5. DOI: https://doi.org/10.1007/s11606-008-0699-5
[30] Osborne RH, Batterham RW, Elsworth GR, Hawkins M, Buchbinder R. The grounded psychometric development and initial validation of the Health Literacy Questionnaire (HLQ). BMC Public Health 2013;13:658. https://doi.org/10.1186/1471-2458-13-658. DOI: https://doi.org/10.1186/1471-2458-13-658
[31] Chinn D, McCarthy C. All Aspects of Health Literacy Scale (AAHLS): Developing a tool to measure functional, communicative and critical health literacy in primary healthcare settings. Patient Education and Counseling 2013;90:247–53. https://doi.org/10.1016/j.pec.2012.10.019. DOI: https://doi.org/10.1016/j.pec.2012.10.019
[32] Sørensen K, Van den Broucke S, Pelikan JM, Fullam J, Doyle G, Slonska Z, Kondilis B, Stoffels V, Osborne RH, Brand H, HLS-EU Consortium. Measuring health literacy in populations: illuminating the design and development process of the European Health Literacy Survey Questionnaire (HLS-EU-Q). BMC Public Health 2013;13:948. https://doi.org/10.1186/1471-2458-13-948. DOI: https://doi.org/10.1186/1471-2458-13-948
[33] Kaphingst KA, Ali J, Taylor HA, Kass NE. Rapid Estimate of Adult Literacy in Medicine: Feasible by Telephone? Fam Med 2010;42:467–8.
[34] Náfrádi L, Papp-Zipernovszky O, Schulz PJ, Csabai M. Measuring functional health literacy in Hungary: Validation of S-TOFHLA and Chew screening questions. Central European Journal of Public Health 2019;27:320–5. https://doi.org/10.21101/cejph.a4885. DOI: https://doi.org/10.21101/cejph.a4885
[35] Housten AJ, Lowenstein LM, Hoover DS, Leal VB, Kamath GR, Volk RJ. Limitations of the S-TOFHLA in measuring poor numeracy: a cross-sectional study. BMC Public Health 2018;18:405. https://doi.org/10.1186/s12889-018-5333-9. DOI: https://doi.org/10.1186/s12889-018-5333-9
[36] Kincaid H, Coyne CA, Hamadani R, Friel T. Validation of three health literacy screening questions compared with S-TOFHLA in a low-income diverse English- and Spanish-Speaking population. J Public Health (Oxf) 2024;46:383–91. https://doi.org/10.1093/pubmed/fdae035. DOI: https://doi.org/10.1093/pubmed/fdae035
[37] Davis TC, Wolf MS, Arnold CL, Byrd RS, Long SW, Springer T, Kennen E, Bocchini JA. Development and validation of the Rapid Estimate of Adolescent Literacy in Medicine (REALM-Teen): a tool to screen adolescents for below-grade reading in health care settings. Pediatrics 2006;118:e1707-1714. https://doi.org/10.1542/peds.2006-1139. DOI: https://doi.org/10.1542/peds.2006-1139
[38] Welch VL, VanGeest JB, Caskey R. Time, Costs, and Clinical Utilization of Screening for Health Literacy: A Case Study Using the Newest Vital Sign (NVS) Instrument. J Am Board Fam Med 2011;24:281–9. https://doi.org/10.3122/jabfm.2011.03.100212. DOI: https://doi.org/10.3122/jabfm.2011.03.100212
[39] Johnson K, Weiss BD. How Long Does It Take to Assess Literacy Skills in Clinical Practice? J Am Board Fam Med 2008;21:211–4. https://doi.org/10.3122/jabfm.2008.03.070217. DOI: https://doi.org/10.3122/jabfm.2008.03.070217
[40] Shealy KM, Threatt TB. Utilization of the Newest Vital Sign (NVS) in Practice in the United States. Health Communication 2016;31:679–87. https://doi.org/10.1080/10410236.2014.990079. DOI: https://doi.org/10.1080/10410236.2014.990079
[41] Weiss BD. The Newest Vital Sign: Frequently Asked Questions. Health Lit Res Pract 2018;2:e125–7. https://doi.org/10.3928/24748307-20180530-02 DOI: https://doi.org/10.3928/24748307-20180530-02
[42] Literacy I of M (US) R on H. Population-Based Approaches to Assessing Health Literacy. Measures of Health Literacy: Workshop Summary, National Academies Press (US); 2009.
[43] Guzys D, Kenny A, Dickson-Swift V, Threlkeld G. A critical review of population health literacy assessment. BMC Public Health 2015;15:215. https://doi.org/10.1186/s12889-015-1551-6. DOI: https://doi.org/10.1186/s12889-015-1551-6
[44] Hawkins M, Gill SD, Batterham R, Elsworth GR, Osborne RH. The Health Literacy Questionnaire (HLQ) at the patient-clinician interface: a qualitative study of what patients and clinicians mean by their HLQ scores. BMC Health Serv Res 2017;17:309. https://doi.org/10.1186/s12913-017-2254-8. DOI: https://doi.org/10.1186/s12913-017-2254-8
[45] Budhathoki SS, Hawkins M, Elsworth G, Fahey MT, Thapa J, Karki S, Basnet LB, Pokharel PK, Osborne RH. Use of the English Health Literacy Questionnaire (HLQ) with Health Science University Students in Nepal: A Validity Testing Study. Int J Environ Res Public Health 2022;19:3241. https://doi.org/10.3390/ijerph19063241. DOI: https://doi.org/10.3390/ijerph19063241
[46] Ha Dinh TT, Bonner A. Psychometric properties of the health literacy questionnaire tested in Vietnamese adults with chronic diseases. BMC Public Health 2025;25:44. https://doi.org/10.1186/s12889-024-21156-7. DOI: https://doi.org/10.1186/s12889-024-21156-7
[47] Yadate T, Girma E, Tadesse Y, Dejene T, Abebe F. Adaptation and validation of the All Aspects of Health Literacy Scale (AAHLS) in healthcare settings of Addis Ababa, Ethiopia. Arch Public Health 2024;82:120. https://doi.org/10.1186/s13690-024-01343-z. DOI: https://doi.org/10.1186/s13690-024-01343-z
[48] Linguistic adaptation and validation of All Aspects of Health Literacy Scale (AAHLS): A health literacy assessment tool for use in Hindi-speaking population - The National Medical Journal of India n.d. https://nmji.in/linguistic-adaptation-and-validation-of-all-aspects-of-health-literacy-scale-aahls-a-health-literacy-assessment-tool-for-use-in-hindi-speaking-population/ (accessed September 12, 2025).
[49] HLS-EU Consortium. Comparative Report on Health Literacy in Eight EU Member States. Europe: The European Health Literacy Project. 2009.
[50] Zanini DS, Peixoto EM, de Andrade JM, Fernandes IA, da Silva MPP. European health literacy survey questionnaire short form (HLS-Q12): adaptation and evidence of validity for the Brazilian context. Psicol Reflex Crit 2023;36:25. https://doi.org/10.1186/s41155-023-00263-1. DOI: https://doi.org/10.1186/s41155-023-00278-8
[51] Pelikan JM, Ganahl K, Broucke SV den, Sørensen K. Measuring health literacy in Europe: Introducing the European Health Literacy Survey Questionnaire (HLS-EU-Q). International Handbook of Health Literacy, Policy Press; 2019, p. 115–38. DOI: https://doi.org/10.56687/9781447344520-011
[52] Duong TV, Aringazina A, Baisunova G, Nurjanah, Pham TV, Pham KM, Truong TQ, Nguyen KT, Oo WM, Mohamad E, Su TT, Huang H-L, Sørensen K, Pelikan JM, Van den Broucke S, Chang PW. Measuring health literacy in Asia: Validation of the HLS-EU-Q47 survey tool in six Asian countries. Journal of Epidemiology 2017;27:80–6. https://doi.org/10.1016/j.je.2016.09.005. DOI: https://doi.org/10.1016/j.je.2016.09.005
[53] Gustafsdottir SS, Sigurdardottir AK, Arnadottir SA, Heimisson GT, Mårtensson L. Translation and cross-cultural adaptation of the European Health Literacy Survey Questionnaire, HLS-EU-Q16: the Icelandic version. BMC Public Health 2020;20:61. https://doi.org/10.1186/s12889-020-8162-6. DOI: https://doi.org/10.1186/s12889-020-8162-6
[54] Sørensen K, Pelikan JM, Röthlin F, Ganahl K, Slonska Z, Doyle G, Fullam J, Kondilis B, Agrafiotis D, Uiters E, Falcon M, Mensing M, Tchamov K, Broucke S van den, Brand H, on behalf of the HLS-EU Consortium. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). Eur J Public Health 2015;25:1053–8. https://doi.org/10.1093/eurpub/ckv043 DOI: https://doi.org/10.1093/eurpub/ckv043
[55] Debussche X, Lenclume V, Balcou-Debussche M, Alakian D, Sokolowsky C, Ballet D, Elsworth GR, Osborne RH, Huiart L. Characterisation of health literacy strengths and weaknesses among people at metabolic and cardiovascular risk: Validity testing of the Health Literacy Questionnaire. SAGE Open Medicine 2018;6. https://doi.org/10.1177/2050312118801250. DOI: https://doi.org/10.1177/2050312118801250
[56] Baker DW. The Meaning and the Measure of Health Literacy. J Gen Intern Med 2006;21:878–83. https://doi.org/10.1111/j.1525-1497.2006.00540.x. DOI: https://doi.org/10.1111/j.1525-1497.2006.00540.x
[57] Literacy I of M (US) C on H, Nielsen-Bohlman L, Panzer AM, Kindig DA. Introduction. Health Literacy: A Prescription to End Confusion, National Academies Press (US); 2004. DOI: https://doi.org/10.17226/10883
[58] Jessup RL, Beauchamp A, Osborne RH, Hawkins M, Buchbinder R. Health literacy measurement: a comparison of four widely used health literacy instruments (TOFHLA, NVS, HLS-EU and HLQ) and implications for practice. Aust J Prim Health 2024;30. https://doi.org/10.1071/PY22280. DOI: https://doi.org/10.1071/PY22280
[59] Marshall N, Butler M, Lambert V, Timon CM, Joyce D, Warters A. Health literacy interventions and health literacy-related outcomes for older adults: a systematic review. BMC Health Services Research 2025;25:319. https://doi.org/10.1186/s12913-025-12457-7. DOI: https://doi.org/10.1186/s12913-025-12457-7
