Health literacy in planning and evaluation

It’s important to consider health literacy at all stages of a project. 

On this page:

Health Literacy Planning Checklist

When planning a project or service, consider the below points. You may have already considered them in your planning. Think through them now with a health literacy lens.

Will there be particular groups that are not able to access this service?


  • Geography
  • Disability
  • Cultural safety
  • Language
  • Transport
  • Cost
  • Technology requirements
  • Has there been any consumer input around accessibility?

Is the information you want to give people accessible and easy to understand?


  • Where it is available?
  • What language is used?
  • How do people find out about the service/project?
  • Is there a hidden cost in obtaining that information? (internet access, printing, attending a service to have access to the information)
  • How do people know the information is reliable?
  • Have you had any consumer feedback on this information?


  • Operating hours
  • Eligibility requirements
  • Ongoing commitment required from health professionals and consumers
  • Ongoing costs for health professionals, the service and consumers
  • Administrative requirements (forms, registrations, referrals)
  • Automated reminder systems
  • Have consumers been involved in evaluating the service?


  • Is it clear what someone has to do once they have seen you? (go to the pharmacy, see a GP for a referral, etc.)
  • Has anyone checked if someone understands what other services may be available to help them or where they can find this information?
  • Is it clear whether your service/project is ongoing or whether it will not be available after a certain time? E.g. a flu vaccination clinic may only operate during certain months.


  • What do you want people to do with the information you give them? Ensure the action or plan is clear.
  • Is this plan documented and shared with all health professionals relevant to that person’s care?
  • Does it allow flexibility to work around patient goals and lifestyle?
  • Do they understand who to call if they have questions or need help?
  • Are they given the opportunity to ask questions?
  • Do care providers use methods like Teach-back, Ask me 3, etc. to encourage discussion and check understanding
  • Do people feel understood and supported by care providers?
  • What resources are offered to help people manage their care at home?

The best way to make sure we are meeting people’s health and health literacy needs, is to include consumers in the design of our project/initiative/activity.

See our partnering with consumers page for tips on how you can do this.

You may be able to think of other considerations relevant to health literacy that apply to your project.

Examples of health literacy improvements

  • Setting up a recall or reminder system for patients
  • Training practice nurses in health coaching
  • Including information about parking and public transport routes on your website
  • Providing access to information in other languages
  • Using and documenting teach-back at follow up appointments
  • Providing resources for patients to record information and questions during consultations
  • Introducing an organisational policy around health literate consumer information
  • Encouraging patients to include carers and family members in their care
  • Offering all patients help to fill in forms
  • Co-designing new models of care
  • Training all staff in cultural competency

Basically, it is anything that makes it easier for people to:

Health literacy evaluation



We don’t recommend measuring health literacy in routine clinical settings.

Some tools, like screening questions, may be more appropriate than performance based tools or longer measures in clinical settings.

We recommend that you use Universal Precautions when communicating with people in clinical settings rather than any formal measures of health literacy. That means, not making any assumptions about what a person may or may not understand, and using best-practice health literacy strategies to communicate with everyone.

If you use these strategies, like using plain language, it helps everyone better understand their health, regardless of what health literacy level they may have. Strategies like Teach-back to check for prior knowledge or understanding of particular topics, and asking people how they like to communicate and learn, allow us to tailor information to an individual without having to “test” them with one of these measurements.

If you are working on a research project, or quality improvement, it may be appropriate to measure individual health literacy.

Over one hundred instruments measuring health literacy in adults exist. There are general and disease specific measures of health literacy, e.g. 6-item Cancer Health Literacy Test (CHLT-6) and Literacy Assessment for Diabetes (LAD).

We may want to measure health literacy to:

  • Describe a population
  • Explore the association between health literacy and health outcomes
  • Plan and monitor effectiveness of interventions
  • Target clinical communication
  • See its effect as an independent contribution to health outcomes (separate to education and literacy)

Some of the most commonly used tools to measure general health literacy across populations and settings are detailed in the table below. For more tools, see:

Type of assessment Aspect of health literacy assessed Validity and reliability settings used in What does the participant have to do? How is it scored? Cost Administration
Screening questions for limited health literacy Chew et al., 2008 Screening Self-reported Identify adults in need of help with printed health material
  • Performs reasonably well in detecting “limited/ marginal” health literacy.
  • Does not perform well in detecting “marginal” health literacy
  • Suitable for clinical practice and research
  • May not be sensitive enough to detect change in health literacy or associations with outcomes
1."How often do you have someone help you read hospital materials?" 2."How confident are you filling out medical forms by yourself?” 3. "How often do you have problems learning about your medical condition because of difficulty understanding written information?" Possible responses:
  • 0 Extremely
  • 1 Quite a bit
  • 2 Somewhat
  • 3 A little bit
  • 4 Not at all
Higher scores reflect greater problems with reading. Categories:
  • 1.Limited/ marginal (corresponds to <9th grade reading level on the REALM)
  • 2. Adequate
Easy to use and administer Less than 1 min Self-administered
Single Item Literacy Screener (SILS) Source: Morris et al. BMC Fam Practice (2006) 7:1 Screening Self-reported
  • Performs reasonably well in detecting limited health literacy
  • Does not perform well in detecting marginal health literacy (sensitivity of 34%)
  • May not be sensitive enough to detect change in health literacy or associations with outcomes
"How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?" Possible responses:
  1. Never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always
Scores greater than 2 indicate some difficulty with reading printed health related material. Categories:
  • 1.Limited (corresponds to S TOFHLA limited/ marginal categories)
  • 2. Adequate
Free Less than 1 min Self-administered
Rapid Estimate of Adult Literacy in Medicine (REALM) Source: Davis et al. Family Medicine (1991) 23:6 Measurement tool Performance based (“test”) Functional health literacy only
  • Established reliability and validity
  • Only identifies those with reading levels below grade 9
66 word recognition and pronunciation test Asks patients to read medical words aloud There is a short version with 7 medical terms. 4 categories of scores:
  • ≤3rd grade
  • 4-6th grade
  • 7-8th grade
  • high school
Free 1-2 minutes to complete Not self-administered
Test of Functional Health Literacy in Adults (TOFHLA) Source: Parker et al. JGIM (1995) 10:10 Measurement tool Performance based (“test”) Functional health literacy only Part 1: 17 item numeracy test– assesses ability to use numerical skills to comprehend directions (e.g. medication instructions). Part 2: 50 item reading comprehension test – patients have to fill in the blanks with one of four options in a medical-related sentence. Different reading levels:
  • 4th grade level
  • 10th grade level
  • 19th grade level.
Licence required
S-TOFHLA Measurement tool Performance based (“test”) Functional health literacy only
  • Established reliability and validity in English
Two reading passages only 3 categories:
  • Limited
  • Marginal
  • Adequate
Licence required 7 minutes Self-administered
Newest Vital Sign Source: Weiss et al. Ann Fam Med (2005) 3:6 Measurement tool Performance based (“test”) Functional health literacy only
  • Established reliability and validity in English
  • Reliability and validity poorer in other languages (Spanish)
  • May misclassify patients with adequate health literacy, and overestimate the percentage of patients with limited literacy
6 questions based on a nutritional (ice cream) label 3 categories:
  • High likelihood of limited literacy
  • Possibility of limited literacy
  • Adequate literacy
Free 3 - 5 minutes Not self administered (presented verbally to patient)
Health Literacy Questionnaire (HLQ) Measurement Self-reported Multi-dimensional tool health literacy strengths and limitations of individuals and populations across 9 domains (goes beyond functional skills)
  • Validity studies completed
  • Used by the Australian Bureau of Statistics to measure health literacy in the Australian population
  • Can be used to inform health literacy interventions
  • Able to detect change in health literacy
44 item questionnaire over 9 domains:
  1. Feeling understood and supported by health care providers
  2. Having sufficient information to manage my health
  3. Actively managing my health
  4. Social support for health
  5. Appraisal of health information
  6. Ability to actively engage with health care providers
  7. Navigating the health care system
  8. Ability to find good health information
  9. Understand health information well enough to know what to do
9 scale scores These cannot be averaged into one score. Licence required (but may be free for NSW Health staff) 7 - 45 minutes Self or verbally administered on paper or online Available in multiple languages
Conversational Health Literacy Assessment Tool (CHAT) Screening Self-reported Used to help identify health literacy support needs, barriers and challenges that may be preventing patients from managing and maintaining their health
  • Not a measure
  • CHAT can be used as part of your existing intake and assessment procedures to gather a broader perspective of a patient's health literacy level.
  • You can also choose to use CHAT as part of discharge planning to help tailor any follow-up care required to the patient's individual health literacy needs
1. Supportive professional relationships
  • Who do you usually see to help you look after your health?
  • How difficult is it for you to speak with [that provider] about your health?
2. Supportive personal relationships
  • Aside from healthcare providers, who else do you talk with about your health?
  • How comfortable are you to ask [that person] for help if you need it?
3. Health information access and comprehension
  • Where else do you get health information that you trust?
  • How difficult is it for you to understand information about your health?
4. Current health behaviours
  • What do you do to look after your health on a daily basis?
  • What do you do to look after your health on a weekly basis?
5. Health promotion barriers and support
  • Thinking about the things you do to look after your health, what is difficult for you to keep doing on a regular basis?
  • Thinking about the things you do to look after your health, what is going well for you?
CHAT questions are not intended to be delivered as a checklist. They help you to shape an open conversation around the literacy themes. Free Not self-administered, meant to be a conversation with patient Administration time depends on number of questions asked

This information is based off the following Health Literacy Hub presentation: Measuring Health Literacy

JargonPlain Language
Pre-opBefore surgery
ECGElectrical picture of your heart
PRNWhen needed
SupineOn back
Discharge planningMaking a plan to get out of hospital
FastDo not eat during this time
SatsOxygen in blood
PathologySomething is not working right
Verbal comprehensionUnderstanding what other people are saying
FebrileHigh temperature
GaitWalking pattern
BilateralBoth sides
AbstainDon’t do
UF goalHow much fluid we want to take off
Primary health assessmentHealth check with GP
ProphylacticTo prevent
QID4 times a day
PivotChanging from an old strategy
AF(atrial fibrillation) Heart flutter/irregular heart rate
Nil by mouthNothing to eat or drink
Upper limbsArms
DyspnoeaShortness of breath
AnalgesiaPain relief

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