FPIN's Help Desk Answers

Health Literacy Tools in the Outpatient Setting


Am Fam Physician. 2017 Aug 15;96(4):252.

Clinical Question

Which screening tools are effective at identifying patients with limited health literacy in the outpatient setting?

Evidence-Based Answer

Single-question screening tools regarding the need for help with understanding and completing medical forms and reading materials can be effective for detecting inadequate health literacy in the outpatient setting. The current standard tools, the Short Test of Functional Health Literacy for Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM), are effective but more difficult to administer. (Strength of Recommendation: B, based on three cohort studies.)

Evidence Summary

A 2013 convenience sample study of 599 English-speaking adults 18 to 80 years of age from six family medicine clinics compared a self-administered screen consisting of three questions (How often do you have problems learning about your medical condition because of difficulty understanding written information? How confident are you filling out medical forms by yourself? How often do you have someone help you read instructions, pamphlets, or other written materials from your doctor or pharmacy?) with the S-TOFHLA, a validated 36-item oral comprehension test for measuring health literacy.1 Each participant completed both assessments. Compared with the S-TOFHLA, the combination of all three screening questions had greater accuracy than any question alone. The question with the greatest accuracy was “How often do you have someone help you read instructions, pamphlets, or other written materials from your doctor or pharmacy?” (area under the receiver operating characteristic [ROC] curve = 0.83; 95% confidence interval [CI], 0.70 to 0.95). There was a low prevalence of inadequate health literacy (2.5%), as determined by the S-TOFHLA.

A 2008 survey of 1,796 adult veterans from four outpatient Veterans Affairs medical centers compared the performance of three screening questions with the S-TOFHLA and REALM via in-person interviews that

Address correspondence to Anne Mounsey, MD, at anne_mounsey@med.unc.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


1. Schwartz KL, et al. Estimating health literacy in family medicine clinics in metropolitan Detroit. J Am Board Fam Med. 2013;26(5):566–570.

2. Chew LD, et al. Validation of screening questions for limited health literacy in a large VA outpatient population. J Gen Intern Med. 2008;23(5):561–566.

3. Wallace LS, et al. Brief report: screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006;21(8):874–877.

Help Desk Answers provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net/?o=1025).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to http://www.fpin.org or e-mail: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, Assistant Medical Editor.

A collection of FPIN's Help Desk Answers published in AFP is available at https://www.aafp.org/afp/hda.

Copyright Family Physicians Inquiries Network. Used with permission.



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Feb 15, 2018

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