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All Aspects of Health Literacy Scale (AAHLS): Developing a tool to measure functional, communicative and critical health literacy in primary healthcare settings

Deborah Chinn a,*, Catherine McCarthy b

a Florence Nightingale School of Nursing and Midwifery, King’s College London, London, UK b Tower Hamlets Community Health Services, London, UK


Article history:

Received 18 August 2011

Received in revised form 3 October 2012

Accepted 12 October 2012


Health literacy

Patient–healthcare practitioner


Scale development


Primary healthcare


Objective: Our aim was to develop and pilot a tool to measure health literacy in primary health care

settings, encompassing functional, communicative and critical health literacy.

Methods: Following consultation with providers and users of primary health care we developed a

fourteen-item self-report scale, which was piloted on 146 participants. The reliability, content and

construct validity of the scale was investigated as well as relationships between scores on the scales and

participant characteristics.

Results: The overall scale had adequate reliability (Cronbach’s alpha = 0.74), though reliability of the

subscales was less consistent. Principal component analysis indicated that scale items loaded on four

factors, corresponding to skills in using written health information; communicating with health care

providers; health information management and appraisal assertion of individual autonomy with regards

to health. Overall scores and different subscale scores were associated with ethnic minority status,

educational level, and self-rated health status, though the picture was complex.

Conclusion: Health literacy is a complex and evolving construct. Nevertheless, we succeeded in

developing a brief measure relating to different health literacy competencies, beyond functional literacy


Practice implications: Assessment using the AAHLS can provide important information for health care

practitioners about the health literacy needs and capabilities of service users.

� 2012 Elsevier Ireland Ltd. All rights reserved.

Contents lists available at SciVerse ScienceDirect

Patient Education and Counseling

jo ur n al h o mep ag e: w ww .e lsev ier . co m / loc ate /p ated u co u

1. Introduction

The concept of health literacy originated within the US public health arena and is broadly defined as ‘the capacity of an individual to obtain, interpret and understand basic health information and

services in ways that are health-enhancing’ [1]. Health literacy is now understood as a social determinant of health impacting on health outcomes for patients with a range of conditions [2–4]. There is a growing recognition that inadequate health literacy contributes to health inequalities as it is more prevalent among lower socioeconomic groups, ethnic minorities, the elderly and those with long-term conditions or disabilities [1]. Health workers are urged to assess the health literacy of service users [5] in order to identify service users who might need additional support. However, they are confronted with contrasting conceptualisations

* Corresponding author at: King’s College London, Florence Nightingale School of

Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, London

SE1 8WA, UK. Tel.: +44 20 7848 3636.

E-mail address: deborah.chinn@kcl.ac.uk (D. Chinn).

0738-3991/$ – see front matter � 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pec.2012.10.019

of this term and little guidance about the sort of assessment that would be most appropriate, especially in socially deprived and ethnically diverse areas.

Recent reviews of existing measures of health literacy suggest a degree of dissatisfaction among communities of researchers and healthcare providers regarding the theoretical underpinnings of current measures, their reliability and validity, and suitability to real life healthcare settings [6–8]. Measuring health literacy is likely to be a particular challenge as it is an emerging and evolving construct [9]. Initially researchers defined health literacy quite narrowly and closely related to reading, writing and numeracy skills as ‘being able to apply literacy skills to health related materials such as prescriptions, appointment cards, medicine labels, and

directions for home health care’ [10]. The Test of Functional Health Literacy in Adults (TOFHLA), the Rapid Estimate of Adult Literacy in Medicine (REALM) and the Set of Brief Screening Questions (SBSQ) were developed to assess these skills, either through direct testing of reading abilities [10–12] or self-report [13,14].

Subsequent reconceptualisations of the health literacy con- struct have argued that individuals need a wider range of

D. Chinn, C. McCarthy / Patient Education and Counseling 90 (2013) 247–253248

cognitive and social skills for dealing with and acting on health information in all its presentations, beyond basic reading and writing skills [15–17]. There has been increasing interest in developing definitions of health literacy based on service users’ own understandings of the term [18–20] and in understanding health literacy in its social and institutional context. Papen suggests that competencies in health literacy should be seen as distributed within the individual health service user’s immediate social circle [21]. Others argue that focusing only on the health literacy skills demonstrated by the service user misses the contribution of health care providers in supporting or undermining the achievement of health literacy [22–24].

Other dimensions of health literacy measures that have come under scrutiny are their applicability, feasibility and acceptability. Some measures take up to half an hour to administer (approxi- mately 22 min in the case of the TOFHLA), and require that administrators have special training and skills which need frequent refreshing and updating [25]. Putting service users in the position where they are struggling to read out loud can evoke feelings of shame and embarrassment [26]. There is also the issue of the cultural and gender specificity of health literacy skills which are being assessed [27,28]. Stimulus materials developed in the US, for example the nutritional label for a tub of icecream [12], may be unfamiliar to service users in other countries. More generally, different health systems may demand different key health literacy skills, whether it is being able to fill in health insurance forms in the US [14] or understanding the public health context of schistosomiasis in China [29]. Health literacy measures need to reflect local health priorities and belief systems, and in the UK, the experiences of patients who do not speak English as a first language [30,31].

1.1. Study aims

With all this in mind, as primary healthcare based clinicians and researchers our goal was to create a measure of health literacy which would be appropriate to use in primary care settings in Tower Hamlets. This is an inner London borough characterised by a mixture of vibrant social and cultural activity, social deprivation and ethnic diversity [32]. We wanted to develop a tool which was quick and easy to use in primary care contexts, took account of local knowledge and expertise and addressed a range of health literacy skills, using Nutbeam’s health promotion orientated model [15]. Nutbeam describes three levels of health literacy: basic/functional literacy, which corresponds to basic reading and writing skills and basic knowledge of health conditions and health systems; communi- cative/interactive literacy, communicative and social skills which can be used to extract information and derive meaning from different forms of communication and to apply new information to changing circumstances; and critical literacy, the advanced cognitive and social skills, which can be applied to critically analyse information, and to use this information to exert greater control over life events and situations relating to individual and community level wellbeing goals.

We also intended the measure would be able to achieve different goals: to act as a screening tool to provide population- level information for commissioners and managers of local primary health and public health services; to alert health practitioners to individual health literacy needs and competencies and to evaluate the impact of local patient education initiatives which were at least partly designed to improve aspects of health literacy, such as expert patient self-management programmes [33], and ESOL (English as a Second or Other Language) classes focusing on health [34].

2. Methods

2.1. Project design

Our first step in designing the new measure was to undertake a review of published research on health literacy definitions and concepts, and on its measurement. Next, we drew up a list of potential items and then presented them in the course of a local consultation exercise consisting of 10 interviews with health service managers and commissioners, and seven focus groups with health workers and local service users. We received some very useful feedback in these sessions. We were repeatedly advised to simplify the language and administration of the measure (we subsequently reduced response options from a 5-point to a 3-point scale featuring the prompts ‘‘rarely’’, ‘‘sometimes’’ and ‘‘often’’) and were offered ideas for new original items. We ran a small pre- pilot involving healthcare assistants undertaking health checks with new patients in GP surgeries, to test the ease of use of the scale and its face validity with health care staff and patients. Finally we undertook the pilot study in three community and five primary healthcare settings in Tower Hamlets.

2.2. Creation of the measure

The measure items were constructed to reflect the dimensions of health literacy in Nutbeam’s [15] definition encompassing functional, communicative and critical health literacy. For functional health literacy items, we reviewed standardised self- report measures devised by Chew et al. [13,14] as well as questionnaires previously used with healthcare users in Tower Hamlets in a social marketing campaign [32]. Items were selected to assess patients’ ability to read health information; writing ability, and access to support networks (see questions FQ1–FQ4 in Table 2). We did not retain all the items or the original wording of the US research, as participants in our consultation exercise found the sentence construction too complex, or felt that the questions related to the US health system. Bearing in mind recent reconceptualisations of health literacy as a set of ‘‘distributed competencies’’, an aggregate score for items 1 and 2 was calculated to look at relationship between limited functional health literacy and access to support.

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