JGIM
ORIGINAL ARTICLES
The Test of Functional Health Literacy in Adults:
A New Instrument for Measuring Patients' Literacy Skills
Ruth M. Parker, MID, David W. Baker, MD, MPH, Mark V. Williams, MD,
Joanne R. Nurss, PhD
OBJECT/VE: To develop a valid, reliable i n s t r u m e n t to m e a -
sure the functional h e a l t h literacy o f patients.
D E S I G N : The Test of F u n c t i o n a l Health Literacy in A d u l t s
[TOFHLA) w a s developed u s i n g actual hospital materials. The
TOFHLA consists of a 5 0 - i t e m reading c o m p r e h e n s i o n and
17-item numerical ability test, t~klng up to 2 2 m i n u t e s to
sdmini~ter. The TOFHLA, the Wide Range A c h i e v e m e n t Test--
Revised (WRAT-R), and the Rapid Estimate o f Adult Literacy
in Medicine (REALM) were a d m i n i s t e r e d for c o m p a r i s o n . A
Spanish version w a s also d e v e l o p e d (TOFHLA-S).
S E T T I N G : Outpatient settings in two public t e a c h i n g h o s -
pltals.
P A T I E N T S : 2 5 6 English- and 2 4 9 S p a n i s h - s p e a k l n g patients
were approached. 78% of the English- and 82% of t h e Span-
ish-spe~klng patients gave informed c o n s e n t , c o m p l e t e d a
demographic survey, a n d t o o k t h e TOFHLA or TOFHLA-S.
R E S U L T S : The TOFHLA s h o w e d good correlation w i t h the
WRAT-R and the REALM [correlation c o e f f i c i e n t s 0 . 7 4 and
0 . 8 4 , respectively). Only 52% o f the E n g l i s h speakers c o m -
pleted more t h a n 80% o f the q u e s t i o n s correctly. 15% o f t h e
patients could not read and interpret a prescription bottle
with instructions to take o n e pill by m o u t h four t i m e s daily,
37% did not u n d e r s t a n d i n s t r u c t i o n s to take a m e d i c a t i o n o n
an empty s t o m a c h , and 48% c o u l d not d e t e r m i n e w h e t h e r
they were eligible for free care.
C O N C L U S I O N S : The TOFHLA is a valid, reliable indicator of
patient ability to read health-related materials. Data s u g g e s t
that a high proportion o f patients c a n n o t perform basic read-
ing tasks. Additional w o r k is n e e d e d to d e t e r m i n e t h e prev-
alence of functional h e a l t h illiteracy and its effect on the
health care experience.
KEY WORDS: functional h e a l t h literacy; literacy and health;
health literacy m e a s u r e m e n t .
J GEN INTERN MED 1 9 9 5 ; 1 0 : 5 3 7 - 5 4 1 .
lliteracy is a well-recognized n a t i o n a l crisis. Results
I from the National Adult Literacy Survey, w h i c h be-
came available S e p t e m b e r 1993, provide the m o s t de-
tailed p o r t r a i t ever available of the c o n d i t i o n of literacy
in our country. The survey of 13,600 i n d i v i d u a l s f o u n d
that 22% of a d u l t A m e r i c a n s , s o m e 40 to 44 million
people, })error m at the lowest skill level. One o f four of
these people reported physical, m e n t a l , or health con-
ditions that keep t h e m from p a r t i c i p a t i n g fully i n work,
school, or housework. One f o u r t h of those i n the lowest
reading level are i m m i g r a n t s whose n a t i v e l a n g u a g e is
not English. ~The prevalence of low literacy is s u p p o r t e d
by data from the U.S. C e n s u s , w h i c h defines illiteracy
as those h a v i n g a n e i g h t h - g r a d e e d u c a t i o n or less. Using
that d e f i n i t i o n of illiteracy, 27 million A m e r i c a n s are
illiterate; a n o t h e r 45 million are only m a r g i n a l l y literate,
m e a n i n g u p to one of every three a d u l t A m e r i c a n s is
functionally illiterate. 2 3 F u n c t i o n a l literacy is the ability
to use reading, writing, a n d c o m p u t a t i o n a l skills at a
level a d e q u a t e to meet the n e e d s of everyday life s i t u a -
tions.
Basic skills in reading, writing, a n d " n u m e r a c y " are
especially i m p o r t a n t in the health care s e t t i n g , where
p a t i e n t p a r t i c i p a t i o n in p l a n n i n g a n d i m p l e m e n t i n g
therapeutic regimens is critical for success. Patients need
to be able to u n d e r s t a n d oral a n d w r i t t e n i n f o r m a t i o n
a b o u t their medical c o n d i t i o n s , follow w r i t t e n a n d n u -
merical d i r e c t i o n s r e g a r d i n g t h e i r t h e r a p e u t i c r e g i m e n s
a n d d i a g n o s t i c tests, ask p e r t i n e n t q u e s t i o n s of medical
personnel, report prior c o n d i t i o n s a n d t r e a t m e n t , a n d
solve problems that arise d u r i n g the c o u r s e of their care.
Adequate f u n c t i o n a l h e a l t h literacy m e a n s b e i n g able to
apply literacy skills to health-related m a t e r i a l s s u c h as
prescriptions, a p p o i n t m e n t cards, m e d i c i n e labels, a n d
directions for h o m e h e a l t h care.
Little h a s b e e n done to explore the i m p a c t of illit-
m
Received f r o m the Emory University School of Medicine {RMP.
DWB, MVW), Atlanta, Georgia; the Harbor-UCLA Medical Cen-
ter {DWB], Los Angeles, California; a n d the Georgia State Uni-
versity (JRN), Atlanta. Georgia.
Presented at the a n n u a l meeting of the Society of General
Internal Medicine. Washington, DC, April 2 7 - 2 9 , 1994, a n d
the a n n u a l meeting of the Robert Wood J o h n s o n Clinical
Scholars. November 10. 1994, Fort Lauderdale. Florida.
Supported by a grant f r o m The Robert Wood J o h n s o n Foun-
dation.
Address correspondence to Dr. Parker: D e p a r t m e n t of Med-
icine, Emory University School o f Medicine. 69 Butler Street.
SE. Atlanta, GA 30303. Reprints are not available.
537
538 Parker et at., Test o f Patients' F u n c t i o n a l Health Literacy
eracy on health care. P u b l i s h e d s t u d i e s i n d i c a t e t h a t
the last grade completed i n school is n o t a good indica-
tor of r e a d i n g ability4 a n d t h a t a s i g n i f i c a n t n u m b e r
of p a t i e n t s have difficulty r e a d i n g d i s c h a r g e i n s t r u c -
tions. 5-7 One s t u d y h a s s h o w n illiteracy a n d poor h e a l t h
s t a t u s to be i n d e p e n d e n t l y associated. 8 S t u d i e s of f u n c -
tional health literacy have b e e n l i m i t e d by the lack of a n
appropriate testing i n s t r u m e n t . Literacy a s s e s s m e n t tools
s u c h as the Wide R a n g e A c h i e v e m e n t T e s t - R e v i s e d
(WRAT-R) 9 c a n be u s e d to a s s i g n a grade level, b u t in-
terpreting results is problematic b e c a u s e grade level does
not necessarily give a n e s t i m a t e of f u n c t i o n a l h e a l t h lit-
eracy. The Rapid E s t i m a t e of Adult Literacy i n Medicine
(REALM), which uses only health-related words, h a s been
used to identify a high p r o p o r t i o n of i n d i g e n t outpa-
tients who h a d poor r e a d i n g ability, l T h e WRAT-R is
not available in S p a n i s h a n d the REALM is n o t valid i n
S p a n i s h . ~' Neither of these i n s t r u m e n t s tests the ability
to read a n d u n d e r s t a n d n u m b e r s , referred to by literacy
experts as n u m e r a c y , or q u a n t i t a t i v e l i t e r a c y . N u m e r -
acy skills m a y be the most i m p o r t a n t e l e m e n t for func-
tional health literacy. To b e t t e r u n d e r s t a n d f u n c t i o n a l
health literacy, we developed the Test of F u n c t i o n a l Health
Literacy i n Adults (TOFHLA). The TOFHLA tests a pa-
tient's ability to read p a s s a g e s (TOFHLA: R e a d i n g Com-
p r e h e n s i o n ) a n d p h r a s e s c o n t a i n i n g n u m b e r s (TOFHLA:
Numeracy) u s i n g real m a t e r i a l s from the h e a l t h care set-
ting. This p a p e r describes how the TOFHLA was devel-
oped a n d the r e s u l t s of i n i t i a l tests.*
METHODS
For test development, a literacy expert reviewed more
t h a n 30 examples of c o m m o n l y u s e d hospital texts, in-
cluding p a t i e n t e d u c a t i o n materials, i n s t r u c t i o n s for di-
agnostic tests, p r e s c r i p t i o n bottle labels a n d i n s t r u c -
tions, a n d p a t i e n t r e g i s t r a t i o n forms. T h e TOFHLA was
developed from a s a m p l e of these i t e m s t h a t were be-
lieved to be widely u s e d a n d of v a r y i n g difficulties. The
test c o n s i s t s of two parts: R e a d i n g C o m p r e h e n s i o n a n d
Numeracy. The R e a d i n g C o m p r e h e n s i o n s e c t i o n is a 50-
item test u s i n g the modified Cloze procedureJ2: that is,
every fifth to s e v e n t h word in a p a s s a g e is omitted. T h e
reader selects from four possible choices, one of w h i c h
is correct a n d three of w h i c h are s i m i l a r b u t g r a m m a t -
ically or contextually incorrect. Passages were selected
from i n s t r u c t i o n s for p r e p a r a t i o n for a n u p p e r g a s t r o i n -
testinal series, the p a t i e n t r i g h t s a n d r e s p o n s i b i l i t i e s
section of a Medicaid a p p l i c a t i o n form, a n d a s t a n d a r d
hospital i n f o r m e d c o n s e n t form. T h e r e a d a b i l i t y levels
*The TOFHLA is copyrighted a n d is a v a i l a b l e upon request
.from: J o a n n e R. Nurss. PhD, Director, Center f o r the S t u d y o f
A d u l t Literacy, Georgia S t a t e University. } University Plaza.
Atlanta, GA, 30303-3083.
JGIM
of the passages on the G u n n i n g Fog i n d e x ~'~ are grades
4.3, 10.4, a n d 19.5, respectively.
The Numeracy s e c t i o n is a 17-item test u s i n g actual
hospital forms a n d labeled p r e s c r i p t i o n vials. It tests a
patient's ability to c o m p r e h e n d d i r e c t i o n s for t a k i n g
medicines, m o n i t o r i n g blood glucose, k e e p i n g clinic ap-
p o i n t m e n t s , a n d o b t a i n i n g f i n a n c i a l a s s i s t a n c e . Pa-
tients are p r e s e n t e d with cue cards or labeled prescrip-
tion bottles a n d asked to r e s p o n d to oral q u e s t i o n s
regarding i n f o r m a t i o n a b o u t the cards or bottles. T h e
overall readability level of the n u m e r a c y p r o m p t s o n the
G u n n i n g Fog index is grade 9.4. The n u m e r a c y score is
multiplied by 2.941 to create a score from 0 to 50, the
same range as that for the r e a d i n g c o m p r e h e n s i o n scores,
The s u m of the reading c o m p r e h e n s i o n a n d the weighted
n u m e r a c y scores yields the TOFHLA score, w h i c h r a n g e s
from 0 to 100 a n d h a s equal c o n t r i b u t i o n s from the two
sections.
Item difficulties (p-values a n d biserial correlations)
for each TOFHLA r e s p o n s e were calculated b a s e d on the
responses from the test p o p u l a t i o n . Items were selected
to o b t a i n a m e d i a n difficulty of 72% for r e a d i n g com-
p r e h e n s i o n a n d 64% for n u m e r a c y . O n e d i s t r a c t o r (an
option that is a n incorrect answer) was c h a n g e d for three
reading c o m p r e h e n s i o n i t e m s a n d six n u m e r a c y i t e m s
were dropped for the final edition. One n u m e r a c y item
asked the r e s p o n d e n t to choose w h i c h of four s p o o n s
represented a tablespoon, n e e d e d for proper d o s i n g of
antacids. Eighty-eight p e r c e n t of the p a t i e n t s could n o t
correctly a n s w e r this q u e s t i o n , w h i c h was t h e n o m i t t e d
in the final v e r s i o n of TOFHLA.
To develop a S p a n i s h version of TOFHLA, or TOFHLA-
S, the r e a d i n g c o m p r e h e n s i o n p a s s a g e s a n d n u m e r a c y
q u e s t i o n s were t r a n s l a t e d i n t o S p a n i s h a n d b a c k t r a n s -
lated into English. D i s c r e p a n c i e s were corrected u s i n g
the c o n s e n s u s of several b i l i n g u a l staff m e m b e r s a n d a
S p a n i s h literacy expert. T h e Cloze p r o c e d u r e was t h e n
performed on each r e a d i n g p a s s a g e to achieve difficulty
comparable to t h a t of the E n g l i s h p a s s a g e i n s t e a d of
u s i n g the s a m e word deletions a n d r e s p o n s e o p t i o n s as
the English version had.
For test development, pilot s t u d i e s were c o n d u c t e d
at Grady Memorial Hospital a n d H a r b o r - U C L A Medical
Center in early 1993. Grady Memorial Hospital is a n
approximately 1,000-bed p u b l i c h o s p i t a l i n Atlanta,
Georgia. The vast majority of p a t i e n t s are African-Amer-
ican i n d i g e n t r e s i d e n t s of Dekalb a n d F u l t o n C o u n t i e s .
The n o n a p p o i n t m e n t a c u t e care clinics are the site of
more t h a n 3 2 0 , 0 0 0 p a t i e n t visits yearly. A c o n v e n i e n c e
sample of 256 p a t i e n t s p r e s e n t i n g for a c u t e care to the
medical walk-in clinic a n d e m e r g e n c y care c e n t e r were
asked by two t r a i n e d research a s s i s t a n t s to p a r t i c i p a t e
in the test d e v e l o p m e n t study. Eleven p e r c e n t were ex-
cluded due to p r e e s t a b l i s h e d criteria, w h i c h i n c l u d e d
age less t h a n 18 years, smell of alcohol o n the b r e a t h .
unintelligible speech, E n g l i s h as a s e c o n d l a n g u a g e ,
overt psychiatric illness, police custody, illness so severe