Journal of Adolescent Health 41 (2007) 312–314

Adolescent health brief

Measuring Adolescent Functional Health Literacy: A Pilot Validation

of the Test of Functional Health Literacy in Adults
Deena J. Chisolm, Ph.D.a,* and Lindsay Buchanan, B.A.b
a
Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
b
Center for Innovation in Pediatric Practice, Columbus Children’s Research Institute, Columbus, Ohio
Manuscript received February 5, 2007; manuscript accepted April 27, 2007

Abstract: Most health literacy tools have been validated only for adults, but health literacy is also important
for adolescents who must increasingly make personal health decisions. This pilot adolescent
validation of the Test of Functional Health Literacy in Adults suggests that the reading compre-
hension component is valid for adolescents. © 2007 Society for Adolescent Medicine. All rights
reserved.
Keywords: Pediatrics; Adolescent; Health Literacy; Measurement

Health literacy has been defined as “the degree to which
individuals have the capacity to obtain, process and under-
stand basic health information and services needed to make
appropriate health care decisions” [1]. Limitations in health
literacy are associated with poor health knowledge [2], lack
of preventive care [3], and higher health costs [4]. It is
estimated that one in four adults have inadequate health
literacy and another 25% have only marginal health lit-
eracy [5]. These limitations pose a great challenge to
public health [6].
To date, most health literacy research has focused on
adults, and some commonly used health literacy measure-
ment tools have been validated only in adult populations.
Adolescent health literacy is important as well, however,
because today’s adolescents are often challenged to manage
their own chronic health conditions and to make important
health-related decisions based on available information. The
Test of Functional Health Literacy in Adults (TOFHLA)
[7], which has not yet been validated in persons less than 18
years of age, could be a valuable tool in measuring adoles-
cent health literacy because it measures not only reading
*Address correspondence to: Deena J. Chisolm, Ph.D., Assistant Pro-
fessor of Pediatrics and Public Health, The Ohio State University, 700
Children’s Drive, Room J1401, Columbus, OH 43205.
E-mail address: chisolmd@ccri.net
1054-139X/07/$ – see front matter © 2007 Society for Adolescent Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2007.04.015
ability but also reading comprehension and computational
skills.
The TOFHLA is unique in its measurement of functional
health literacy and numeracy, or computational skill. Liter-
acy is measured with 50 items in a series of three health-
related reading passages. In each passage, every 5th to 7th
word is deleted. Respondents must select from four possible
choices to fill each blank. For example “The X-Ray will
_____ (TAKE, VIEW, TALK, LOOK) from 1 to 3 _______ (BEDS,
BRAINS, HOURS, DIETS) to do.” Numeracy is measured with 17
analytical questions requiring subjects to interpret informa-
tion on “prompts” including prescription slips and medicine
bottles. For example the respondent is presented a sample
lab report slip reporting, “Normal Blood sugar is 60 —150.
Your blood sugar today is 160.” and asked “If this were
your score, would your blood sugar be normal today?”
Scores on both sections are calculated based on the number
of items answered correctly.
In adults, the TOFHLA has shown excellent internal
reliability with Chronbach’s ␣ of .98. It has strong validity
when compared to two widely used word recognition-based
assessments: the Rapid Estimate of Adult Literacy in Med-
icine (REALM) and the Wide Ranging Achievement Test—
Revised (WRAT-R), with correlations of .84 and .74 re-
spectively. This paper presents a preliminary construct
validation of the TOFHLA in teens using the same method
used previously in adults.
 D.J. Chisolm and L. Buchanan / Journal of Adolescent Health 41 (2007) 312–314
Table 1
Correlation of TOFHLA with other instruments in adolescents
WRAT3 REALM TOFHLA-R TOFHLA-N
WRAT3 1.00
REALM .76 1.00
(p ⬍ .001)
TOFHLA-R 0.59 .60 1.00
(p ⬍ .001) (p ⬍ .001)
TOFHLA-N .11 0.18 .07 1.00
(p ⫽ .45) (p ⫽ .22) (p ⫽ .64)
REALM ⫽ Rapid Estimate of Adult Literacy in Medicine; TOFHLA ⫽
Test of Functional Health Literacy in Adults; WRAT ⫽ Wide Ranging
Achievement Test.
Methods
We recruited 50 young people, aged 13–17 years, using
two methods: (1) telephone solicitation of youth who had
participated in previous studies and volunteered to be con-
tacted for future research, and (2) e-mail solicitation of
hospital staff asking them to refer potentially interested
youth that met the study criteria. Our population included 26
girls and 24 boys. The mean age was 14.7 years (range 13–
17 years). In all, 80% described themselves as white. Re-
cruited youth were scheduled for a 45-minute study visit in
which they completed three literacy assessment tools: the
TOFHLA, the Rapid Estimate of Adult Literacy in Medi-
cine (REALM) [8], and the Wide Ranging Achievement
Test (WRAT-3) [9].
The TOFHLA administration included both the reading
comprehension component (TOFHLA-R) and the numeracy
component (TOFHLA-N) of the assessment. Each compo-
nent was scored based on the number of items answered
correctly using the tool’s scoring instructions and key. We
compared TOFHLA-R and TOFHLA-N scores to scores on
the WRAT-3 and the REALM, both of which assess correct
pronunciation of words presented on a card, in order of
increasing difficulty. The WRAT-3 reading assessment asks
users to read aloud a series of increasingly difficult words.
Scoring is based on number of items correctly pronounced.
Internal reliability for teens, using coefficient ␣ ranges from
.90 to .92 and test–retest reliability ranges from .91 to .98.
Construct validity has been demonstrated through high cor-
relations with age, intelligence scales, and standardized
achievement tests. The REALM uses the same administra-
tion format as the WRAT but is limited to health related-
words. Test–retest reliability is high (.99), and construct
validity has been demonstrated through high correlations
with general reading assessments and academic achieve-
ment tests. Correlations with the WRAT and REALM were
used in the validation of the TOFHLA in adults.
Youth also completed a demographics form collecting
age, grade in school, race, and gender. No personal identi-
fying information was collected. All elements of the study
were approved by the Columbus Children’s Hospital Insti-
tutional Review Board.
313
Each literacy assessment was administered and scored in
a manner consistent with the tool’s documentation by a
research associate who also noted the time required to
complete each instrument and any significant challenges
faced by the youths. Correlations between the tools were
measured to assess validity.
Results and Discussion
Administration of the TOFHLA took an average of 12.9
minutes with a range from 8.9 to 17.3. This is consistent with
adult completion times which are estimated to be between 10
and 20 minutes [8]. No significant differences in administra-
tion time were seen by age or grade in school. No significant
barriers to administration were noted for any participant.
Correlations between the TOFHLA-R and both the
WRAT3 and REALM were statistically significant suggest-
ing that the tools are measuring the same underlying con-
struct. Specifically, in our youth, correlation with the
REALM was .60 and correlation with the WRAT was .59.
These correlations appear somewhat lower than those found
in adult validations of the TOFHLA, .84 for the REALM
and .73 for the WRAT, but the significance of these differ-
ences cannot be tested in this analysis [10].
One notable difference between adult and adolescent
validation was the relationship between the WRAT and
the REALM and the TOFHLA-N. Adult validation of the
TOFHLA-N found significant correlations of .73 with the
REALM and .63 with the WRAT; however, the correlations
of .18 and .11, respectively, found in this pilot were not
statistically significant. While it was expected that the cor-
relations with the TOFHLA-N would be smaller than those
with the TOFHLA-R, the magnitude of the difference was
surprising. This result suggests that the relationship between
reading and numerical skills in adults is much stronger than
that in teens. A possible explanation for this finding relates
to developmental stage. The Theory of Development posits
that between the ages of 11 and 15 youth enter the phase of
Formal Operations, the hallmark of which is logical and
abstract thinking [11]. Such thinking is necessary for the
quantitative problem solving in the TOFHLA-N but may be
less essential for reading assessments. To the extent that our
sample contains variation in developmental stage we should
expect the weaker relationship between reading and nu-
meracy seen in this pilot.
This study supports the use of the TOFHLA-R in ado-
lescent populations. Along with the newly developed
REALM-Teen [12], the TOFHLA can facilitate the study of
relationships between adolescent health literacy and issues
including disease self-management, information-seeking,
and decision-making. Additional research is needed regard-
ing the use of the TOFHLA-N. The primary limitation of
this study is that it was conducted using volunteers who may
not reflect the diversity of adolescent literacy levels. Because
our recruitment materials mentioned a reading activity, it is
314 D.J. Chisolm and L. Buchanan / Journal of Adolescent Health 41 (2007) 312–314
possible that youth or parents of youth with poor reading skills
chose not to volunteer. A more comprehensive validation will
require the use of a representative sample. Table 1
Acknowledgements
This work was supported by the Columbus Children’s
Research Institute. The authors thank Kelly J. Kelleher,
M.D., M.P.H., for substantive review of this manuscript.
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