English and Spanish Health Literacy Assessment Tools Available

AHRQ Publishes Equivalent Spanish – English Health Literacy Assessments

The Short Assessment of Health Literacy–Spanish and English (SAHL–S&E), developed by a grantee of the Agency for Healthcare Research and Quality, are quick tests of individuals’ health literacy. The tests are comparable in English and Spanish, with good reliability and validity in both languages.

The tests consist of 18 items. For each item, persons being examined select which word – a key word with a related meaning or a distractor word unrelated in meaning – is most similar to the item. The tests take approximately 2-3 minutes to administer.

Both tests and their Users Guides are available from: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy/index.html

Health Literacy Measurement Tools | Agency for Healthcare Research & Quality (AHRQ)

Health Literacy Measurement Tools

Fact Sheet

Health Literacy and How to Assess It

Health literacy is the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. AHRQ-funded researchers have developed a variety of tools to measure an aspect of health literacy—individuals' reading comprehension in a medical context.

The AHRQ-supported tools are for the assessment of health literacy in speakers of English and Spanish, the languages most frequently spoken in the United States.

These tools can be used for research, training, or program planning purposes as long as credit is given to AHRQ as the source. (Users of the tools who publish their findings can find a link listed with each tool to the paper that describes its initial development and validation.) The tools available from AHRQ are the:

Note: Direct translation of these tools into another language may not produce a valid assessment of health literacy in the new language. Please contact AHRQ’s Office of Communications and Knowledge Transfer for permission and to be put in contact with a technical expert before attempting a translation.

Short Assessment of Health Literacy–Spanish and English (SAHL-S&E)

The Short Assessment of Health Literacy–Spanish and English (SAHL–S&E) is a new instrument, consisting of comparable tests in English and Spanish, with good reliability and validity in both languages. Persons being examined in English or Spanish are presented with 18 terms and, for each term a key word with a related meaning and a distractor word unrelated in meaning to the test term. This tests the subject’s comprehension as well as pronunciation (decoding) of health-related terms. Administration of the test takes only 2-3 minutes and requires minimal training. Administration of these tests could facilitated by using laminated 4”´5” flash cards, with each card containing a medical term printed in boldface on the top and the two association words—i.e., the key and the distracter—at the bottom.

SAHL–S&E validation study:

Lee S.-Y. D., Stucky B.D., Lee J. Y. et al. Short assessment of health literacy–Spanish and English: A comparable test of health literacy for Spanish and English speakers HSR 2010 August;45(4):1105–20. Pub Med ID (PMID): 20500222 [Full text available in PubMedCentral]

SAHL-S Test Form

Stem	Key or Distracter		"no se" (Don't know)
1. empleo	__trabajo	__educación	__no se
2. convulsiones	__mareado	__tranquilo	__no se
3. infección	__mata	__virus	__no se
4. medicamento	__instrumento	__tratamiento	__no se
5. alcoholismo	__adicción	__recreo	__no se
6. riñón	__orina	__fiebre	__no se
7. dosis	__dormir	__cantidad	__no se
8. aborto espontáneo	__pérdida	__matrimonio	__no se
9. estreñimiento	__bloqueado	__suelto	__no se
10. embarazo	__parto	__niñez	__no se
11. nervios	__aburrido	__ansiedad	__no se
12. nutrición	__saludable	__gaseosa	__no se
13. indicado	__instrucción	__decisión	__no se
14. hormonas	__crecimiento	__harmonía	__no se
15. abnormal	__diferente	__similar	__no se
16. diagnóstico	__evaluación	__recuperación	__no se
17. hemorroides	__venas	__corazón	__no se
18. sífilis	__anticonceptivo	__condón	__no se

The 18 items of SAHL-S, rank-ordered according to the parameter b of item difficulty (keys and distracters are listed in the same random order as in the field interview)

Instruction for Administering SAHL-S

The Short Assessment of Health Literacy-Spanish, or SAHL-S, contains 18 test items designed to assess a Spanish-speaking adult’s ability to read and understand common medical terms. The test could help health professionals estimate the adult’s health literacy level. Administration of the test could facilitated by using laminated 4” X 5” flash cards, with each card containing a medical term printed in boldface on the top and the two association words—i.e., the key and the distracter—at the bottom.

Directions to the Interviewer:

Before the test, the interviewer should say to the examinee:

”Le voy a mostrar tarjetas con 3 palabras en ellas. Primero, me gustaría que usted lea la palabra arriba en voz alta. Entonces, yo leeré las dos palabras debajo a usted y me gustaría que usted me dijera cuál de las dos palabras es más similar a la palabra arriba. Si usted no sabe la respuesta, por favor diga, ‘no se’. No adivine.”
Show the examinee the first card.
The interviewer should say to the examinee:
“Ahora, por favor, lea la palabra arriba en voz alta.”
The interviewer should have a clipboard with a score sheet to record the examinee’s answers. The clipboard should be held such that the examinee cannot see or be distracted by the scoring procedure.
The interviewer will then read the key and distracter (the two words at the bottom of the card) and then say:

“Cuál de las dos palabras es más similar a la palabra arriba? Si usted no sabe la respuesta, por favor diga, ‘no se’.
The interviewer may repeat the instructions so that the examinee feels comfortable with the procedure.
Continue the test with the rest of the cards.
A correct answer for each test item is determined by both correct pronunciation and accurate association. Each correct answer gets one point. Once the test is completed, the interviewer should tally the total points to generate the SAHL-S score.
A score between 0 and 14 suggests the examinee has inadequate health literacy.

SAHL-E Word Sets

Stem	Key or Distracter		Don't know
1. kidney	__urine	__fever	__don't know
2. occupation	__work	__education	__don't know
3. medication	__instrument	__treatment	__don't know
4. nutrition	__healthy	__soda	__don't know
5. miscarriage	__loss	__marriage	__don't know
6.infection	__plant	__virus	__don't know
7. alcoholism	__addiction	__recreation	__don't know
8. pregnancy	__birth	__childhood	__don't know
9. seizure	__dizzy	__calm	__don't know
10. dose	__sleep	__amount	__don't know
11. hormones	__growth	__harmony	__don't know
12. abnormal	__different	__similar	__don't know
13. directed	__instruction	__decision	__don't know
14. nerves	__bored	__anxiety	__don't know
15. constipation	__blocked	__loose	__don't know
16. diagnosis	__evaluation	__recovery	__don't know
17. hemorrhoids	__veins	__heart	__don't know
18. syphilis	__contraception	__condom	__don't know

The 18 items of SAHL-S, rank-ordered according to the parameter b of item difficulty (keys and distracters are listed in the same random order as in the field interview).

Instruction for Administering SAHL-E

Short Assessment of Health Literacy-English (SAHL-E)

Interviewer's Instruction

Directions to the Interviewer:

Before the test, the interviewer should say to the examinee:

“I’m going to show you cards with 3 words on them. First, I’d like you to read the top word out loud. Next, I’ll read the two words underneath and I’d like you to tell me which of the two words is more similar to or has a closer association with the top word. If you don’t know, please say ‘I don’t know’. Don’t guess.”
Show the examinee the first card.
The interviewer should say to the examinee:

“Now, please, read the top word out loud.”
The interviewer should have a clipboard with a score sheet to record the examinee’s answers. The clipboard should be held such that the examinee cannot see or be distracted by the scoring procedure.
The interviewer will then read the key and distracter (the two words at the bottom of the card) and then say:

“Which of the two words is most similar to the top word? If you don’t know the answer, please say ‘I don’t know’.”
The interviewer may repeat the instructions so that the examinee feels comfortable with the procedure.
Continue the test with the rest of the cards.
A correct answer for each test item is determined by both correct pronunciation and accurate association. Each correct answer gets one point. Once the test is completed, the interviewer should tally the total points to generate the SAHL-E score.
A score between 0 and 14 suggests the examinee has low health literacy.

Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF)

The Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF) is a 7-item word recognition test to provide clinicians with a valid quick assessment of patient health literacy. The REALM-SF has been validated and field tested in diverse research setting, and has excellent agreement with the 66-item REALM instrument in terms of grade-level assignments.

REALM-SF Validation study: Arozullah AM, Yarnold PR, Bennett CL, et al. Development and validation of a short-form, rapid estimate of adult literacy in medicine. Med Care 2007 November;45(11):1026–33. PMID: 18049342

Note: This quick tool was developed with AHRQ funding, independently of REALM-R, created by the developers of REALM at Louisiana State University

REALM-SF Form

Select for PDF Version [

- 25.28 KB]

Patient name _______________ Date of birth _______________ Reading level _______________

Date ________________ Examiner _______________ Grade completed _______________

Word
Menopause	☐
Antibiotics	☐
Exercise	☐
Jaundice	☐
Rectal	☐
Anemia	☐
Behavior	☐

Instructions for Administering the REALM-SF

Give the patient a laminated copy of the REALM-SF form and score answers on an unlaminated copy that is attached to a clipboard. Hold the clipboard at an angle so that the patient is not distracted by your scoring. Say:

"I want to hear you read as many words as you can from this list. Begin with the first word and read aloud. When you come to a word you cannot read, do the best you can or say, 'blank' and go onto the next word."
If the patient takes more than five seconds on a word, say "blank" and point to the next word, if necessary, to move the patient along. If the patient begins to miss every word, have him or her pronounce only known words.

Scores and Grade Equivalents for the REALM-SF

Score	Grade range
0	Third grade and below; will not be able to read most low-literacy materials; will need repeated oral instructions, materials composed primarily of illustrations, or audio or video tapes.
1-3	Fourth to sixth grade; will need low-literacy materials, may not be able to read prescription labels.
4-6	Seventh to eighth grade; will struggle with most patient education materials; will not be offended by low-literacy materials.
7	High school; will be able to read most patient education materials.

Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50)

The Short Assessment of Health Literacy for Spanish Adults (SAHLSA-50) is a validated health literacy assessment tool containing 50 items designed to assess a Spanish-speaking adult's ability to read and understand common medical terms. Administration of the test takes 3-6 minutes. The SAHLSA was based on the Rapid Estimates of Adult Literacy in Medicine (REALM), known as the most easily administered tool for assessing health literacy in English. However, it is important to note that SAHLSA-50 results are not comparable with REALM results. Users who are interested in comparing the health literacy ability of English and Spanish speakers are advised to adopt SAHL-S&E.

SAHLSA-50 Validation Study: Lee S.-Y. D., Bender D.E., Ruiz R.E., et al. Development of an easy-to-use Spanish health literacy test. HSR 2006 Aug;41(4, Part I); 1392–412. PMID: 16899014 [Full text available in PubMedCentral]

Select for PDF Version [

- 131.77 KB] .

SAHLSA-50 Form

Stem	Key or Distracter		"no se" (Don't know)
próstata	__glándula	__circulación	__no se
empleo	__trabajo	__educación	__no se
menstrual	__mensual	__diario	__no se
gripe	__sano	__enfermo	__no se
avisar	__medir	__decir	__no se
comidas	__cena	__paseo	__no se
alcoholismo	__adicción	__recreo	__no se
grasa	__naranja	__manteca	__no se
asma	__respirar	__piel	__no se
cafeína	__energía	__agua	__no se
osteoporosis	__hueso	__músculo	__no se
depresión	__apetito	__sentimientos	__no se
estreñimiento	__bloqueado	__suelto	__no se
embarazo	__parto	__niñez	__no se
incesto	__familia	__vecinos	__no se
pastilla	__tableta	__galleta	__no se
testículo	__óvulo	__esperma	__no se
rectal	__regadera	__inodoro	__no se
ojo	__oír	__ver	__no se
irritación	__rígido	__adolorido	__no se
abnormal	__diferente	__similar	__no se
estrés	__preocupación	__feliz	__no se
aborto espontáneo	__pérdida	__matrimonio	__no se
ictericia	__amarillo	__blanco	__no se
papanicolaou	__prueba	__vacuna	__no se
impétigo	__pelo	__piel	__no se
indicado	__instrucción	__decisión	__no se
ataque	__herida	__sano	__no se
menopausia	__señoras	__niñas	__no se
apéndice	__rascar	__dolor	__no se
comportamiento	__pensamiento	__conducta	__no se
nutrición	__saludable	__gaseosa	__no se
diabetes	__azúcar	__sal	__no se
sífilis	__anticonceptivo	__condón	__no se
inflamatorio	__hinchazón	__sudor	__no se
hemorroides	__venas	__corazón	__no se
herpes	__aire	__sexo	__no se
alérgico	__resistencia	__reacción	__no se
riñón	__orina	__fiebre	__no se
calorías	__alimentos	__vitaminas	__no se
medicamento	__instrumento	__tratamiento	__no se
anemia	__sangre	__nervio	__no se
intestinos	__digestión	__sudor	__no se
potasio	__mineral	__proteína	__no se
colitis	__intestino	__vejiga	__no se
obesidad	__peso	__altura	__no se
hepatitis	__pulmón	__hígado	__no se
vesícula biliar	__arteria	__órgano	__no se
convulsiones	__mareado	__tranquilo	__no se
artritis	__estómago	__articulación	__no se

Scoring Key to SAHLSA-50 Form

Select for PDF version [pdf icon- file size]

(Correct answers are bolded)

Stem	Key or Distracter		"no se" (Don't know)
1. próstata	__glándula	__circulación	__no se
2. empleo	__trabajo	__educación	__no se
3. menstrual	__mensual	__diario	__no se
4. gripe	__sano	__enfermo	__no se
5. avisar	__medir	__decir	__no se
6. comidas	__cena	__paseo	__no se
7. alcoholismo	__adicción	__recreo	__no se
8. grasa	__naranja	__manteca	__no se
9. asma	__respirar	__piel	__no se
10. cafeína	__energía	__agua	__no se
11. osteoporosis	__hueso	__músculo	__no se
12. depresión	__apetito	__sentimientos	__no se
13. estreñimiento	__bloqueado	__suelto	__no se
14. embarazo	__parto	__niñez	__no se
15. incesto	__familia	__vecinos	__no se
16. pastilla	__tableta	__galleta	__no se
17. testículo	__óvulo	__esperma	__no se
18. rectal	__regadera	__inodoro	__no se
19. ojo	__oír	__ver	__no se
20. irritación	__rígido	__adolorido	__no se
21. abnormal	__diferente	__similar	__no se
22. estrés	__preocupación	__feliz	__no se
23. aborto espontáneo	__pérdida	__matrimonio	__no se
24. ictericia	__amarillo	__blanco	__no se
25. papanicolaou	__prueba	__vacuna	__no se
26. impétigo	__pelo	__piel	__no se
27. indicado	__instrucción	__decisión	__no se
28. ataque	__herida	__sano	__no se
29. menopausia	__señoras	__niñas	__no se
30. apéndice	__rascar	__dolor	__no se
31. comportamiento	__pensamiento	__conducta	__no se
32. nutrición	__saludable	__gaseosa	__no se
33. diabetes	__azúcar	__sal	__no se
34. sífilis	__anticonceptivo	__condón	__no se
35. inflamatorio	__hinchazón	__sudor	__no se
36. hemorroides	__venas	__corazón	__no se
37. herpes	__aire	__sexo	__no se
38. alérgico	__resistencia	__reacción	__no se
39. riñón	__orina	__fiebre	__no se
40. calorías	__alimentos	__vitaminas	__no se
41. medicamento	__instrumento	__tratamiento	__no se
42. anemia	__sangre	__nervio	__no se
43. intestinos	__digestión	__sudor	__no se
44. potasio	__mineral	__proteína	__no se
45. colitis	__intestino	__vejiga	__no se
36. obesidad	__peso	__altura	__no se
47. hepatitis	__pulmón	__hígado	__no se
48. vesícula biliar	__arteria	__órgano	__no se
49. convulsiones	__mareado	__tranquilo	__no se
50. artritis	__estómago	__articulación	__no se

Instructions for Administering SAHLSA-50

Administration of the test could be facilitated by using laminated 4" x 5" flash cards, with each card containing a medical term printed in boldface on the top and the two association words—i.e., the key and the distracter—at the bottom.

Directions to the Interviewer:

Before the test, the interviewer should say to the examinee: "Le voy a mostrar tarjetas con 3 palabras en ellas. Primero, me gustaría que usted lea la palabra arriba en voz alta. Entonces, yo leeré las dos palabras debajo a usted y me gustaría que usted me dijera cuál de las dos palabras es más similar a la palabra arriba. Si usted no sabe la respuesta, por favor diga, 'no se'. No adivine."
Show the examinee the first card.
The interviewer should say to the examinee: "Ahora, por favor, lea la palabra arriba en voz alta."
The interviewer should have a clipboard with a score sheet to record the examinee's answers. The clipboard should be held such that the examinee cannot see or be distracted by the scoring procedure.
The interviewer will then read the key and distracter (the two words at the bottom of the card) and then say:"Cuál de las dos palabras es más similar a la palabra arriba? Si usted no sabe la respuesta, por favor diga, 'no se'.
The interviewer may repeat the instructions so that the examinee feels comfortable with the procedure.
Continue the test with the rest of the cards.
A correct answer for each test item is determined by both correct pronunciation and accurate association. Each correct answer gets one point. Once the test is completed, the interviewer should tally the total points to generate the SAHLSA-50 score.
A score between 0 and 37 suggests the examinee has inadequate health literacy.