Journal of General Internal Medicine

, Volume 23, Issue 5, pp 561–566 | Cite as

Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient Population

  • Lisa D. ChewEmail author
  • Joan M. Griffin
  • Melissa R. Partin
  • Siamak Noorbaloochi
  • Joseph P. Grill
  • Annamay Snyder
  • Katharine A. Bradley
  • Sean M. Nugent
  • Alisha D. Baines
  • Michelle VanRyn
Original Article



Previous studies have shown that a single question may identify individuals with inadequate health literacy. We evaluated and compared the performance of 3 health literacy screening questions for detecting patients with inadequate or marginal health literacy in a large VA population.


We conducted in-person interviews among a random sample of patients from 4 VA medical centers that included 3 health literacy screening questions and 2 validated health literacy measures. Patients were classified as having inadequate, marginal, or adequate health literacy based on the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine (REALM). We evaluated the ability of each of 3 questions to detect: 1) inadequate and the combination of “inadequate or marginal” health literacy based on the S-TOFHLA and 2) inadequate and the combination of “inadequate or marginal” health literacy based on the REALM.

Measurements and Main Results

Of 4,384 patients, 1,796 (41%) completed interviews. The prevalences of inadequate health literacy were 6.8% and 4.2%, based on the S-TOHFLA and REALM, respectively. Comparable prevalences for marginal health literacy were 7.4% and 17%, respectively. For detecting inadequate health literacy, “How confident are you filling out medical forms by yourself?” had the largest area under the Receiver Operating Characteristic Curve (AUROC) of 0.74 (95% CI: 0.69–0.79) and 0.84 (95% CI: 0.79–0.89) based on the S-TOFHLA and REALM, respectively. AUROCs were lower for detecting “inadequate or marginal” health literacy than for detecting inadequate health literacy for each of the 3 questions.


A single question may be useful for detecting patients with inadequate health literacy in a VA population.


health literacy screening validation questions 



The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the University of Washington. This study was funded by a grant from VA Health Services Research and Development Service, CRI 03-158 to the Center for Chronic Disease Outcomes Research (CCDOR). Dr. Griffin is also supported by a Merit Review Entry Program award from VA Health Services Research and Development Service. Dr. Katharine Bradley is supported by the Department of Veteran Affairs, Northwest Center of Excellence for Health Services Research and Development, Primary and Specialty Medical Care, and the Center for Excellence in Substance Abuse Treatment and Education.

Conflict of Interest

None disclosed.


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Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Lisa D. Chew
    • 1
    Email author
  • Joan M. Griffin
    • 2
    • 3
  • Melissa R. Partin
    • 2
    • 3
  • Siamak Noorbaloochi
    • 2
    • 3
  • Joseph P. Grill
    • 2
  • Annamay Snyder
    • 2
  • Katharine A. Bradley
    • 4
    • 5
  • Sean M. Nugent
    • 2
  • Alisha D. Baines
    • 2
  • Michelle VanRyn
    • 6
  1. 1.Department of Medicine, Division of General Internal MedicineUniversity of Washington, Harborview Medical CenterSeattleUSA
  2. 2.Center for Chronic Disease Outcomes Research (CCDOR)Minneapolis VA Medical CenterMinneapolisUSA
  3. 3.Department of Medicine, Division of General Internal MedicineUniversity of MinnesotaMinneapolisUSA
  4. 4.Health Services Research & Development, Primary and Specialty Medical Care, and Center of Excellence in Substance Abuse Treatment and EducationVA Puget Sound Health Care SystemSeattleUSA
  5. 5.Department of Medicine and Health ServicesUniversity of WashingtonSeattleUSA
  6. 6.Department of Family Medicine and Community HealthUniversity of MinnesotaMinneapolisUSA

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