Table 2.

Health literacy instruments for children and adolescents

No.	Author, year country language	Instrument	Type	Study aim	Sample size, study population, setting	Scope of measured components	Items, response format	Time of administration	Reliability	Validity, responsiveness and sensitivity
1	Davis et al., 2006 [50] USA English	Rapid Estimate of Adult Literacy in Medicine - Teen (REALM-teen) Adaptation of an existing instrument for adults (REALM)	Objective measurement/performance based assessment	Validation of the REALM-teen for adolescents	N = 1533 10–19 y. participants were 50% black, 53% female; 34% were enrolled in middle school and 66% in high school Secondary school Mixed setting, schools and healthcare setting	Word recognition; Pronunciation	66 items (not provided) Health words arranged in increasing order of difficulty Pronouncing words	Usually 2–3 min, here approx. 3 min	Internal consistency α = .94	Convergent: SORT-R r = .93 WRAT r = .83 Receiver operating characteristic (ROC) analysis: SORT-R Area under ROC (AUC) = .84
2	Brown et al., 2007 [40] USA English	KidsHealth KidsPoll of Health Literacy New instrument based on National Health Education Standards (NHES)	Subjective measurement/self-report	Investigating health literacy and its effects on health behaviour and practice	N = 1178 9–13 y. 5th – 8th grade Secondary school 11 health education centres	Ability to understand, access and apply health information; Interest in health; Belief: Ability that health behaviour is affective; Attitude	8 items (provided) Remote keypads Close-end questions with a maximum of 5 answer choices	Not available (n.a.)	n.a.	n.a.
3	Hubbard and Rainey 2007 [41] USA English	“Health Literacy Instrument” no name. New instrument based on Health Education Assessment Project (HEAP)	Objective measurement/performance based assessment (not explicitly stated by the article but indicated in the text)	To evaluate the influence of comprehensive textbook-based instruction on students’ acquisition of health-related concepts and skills	N = 669 secondary school children and adolescents n = 333 female; n = 333 male; n = 3 missing (Treatment group: n = 330; control group: n = 339) School setting, N = 3 schools (n = 2 middle; n = 1 high school)	Understanding of health concepts about tobacco, physical activity, and nutrition; Ability to access information, interpersonal communication, decision-making, goal setting, and self-management	30 items (not provided) 15 items related to health concepts 15 items related to demonstrate skills	n.a.	Reliability coefficient of the concepts scale α = .76 middle school; α = .72 high school; of the skills scale α = .75 middle school; α = .76 high school HEAP assessment items proved to be reliable	Not provided, HEAP assessment items proved to be valid
4	Chisolm and Buchanan, 2007 [51] USA English	Test of Functional Health Literacy in Adults (TOFHLA) in adolescent population (TOFHLAd), 2 components TOFHLA-R & TOFHLA-N Adaptation of an existing instrument for adults	Objective measurement/performance based assessment	Pilot validation for adolescents	N = 50 13–17 y. n = 26 female; n = 24 male Healthcare setting	Reading comprehension (TOFHLA-R); Numeracy (TOFHLA-N)	67 items (not provided), 2 components; TOFHLA-R has 50 reading comprehension items, cloze procedure; TOFHLA-N has 17 numeracy items	10–20 min: average of 12.9 min with a range from 8.9 to 17.3	n.a.	Concurrent: TOFHLA-R: WRAT3 r = .59 (p < .001) REALM r = .60 (p < .001) TOFHLA-N: WRAT3 r = .11 (p = .45) REALM r = .18 (p = .22)
5	Steckelberg et al., 2009 [48] Germany German	Critical Health Competence Test (CHC) New instrument	Objective measurement/performance based assessment	Development and validation of a questionnaire to measure critical health competencies	N = 429 15–42 y. n = 322 (first field test); n = 255 10th and 11th from secondary schools, n = 67 university students n = 107 (second field test); n = 94 secondary schools, n = 13 university students	A. Understanding medical concepts; B. Skills of searching literature (information seeking); C. Basic statistics (numeracy); D. Design of experiments and sampling	72 items (not provided); Scenarios (S) (items): S1 (16), S2 (20), S3 (15), S4 (21). A, 15 items B, 22 items C, 18 items D, 17 items	Should not exceed 90 min	Rasch analysis: Mean person parameter S1: 395 S2: 497 S3: 635 S4: 473	Construct validity: Cohen’s d = 4.33 [95% CI 3.51–5.16] Rasch model WINMIRA ANOVA = .91
6	Vardavas et al., 2009 [42] Greece Greek	Health Literacy Questionnaire for Children New instrument	Subjective measurement/self-report	To locate the topics and to assess the sources of health information of adolescents	N = 369, 12–18 y. 46.6% male; 53,4% female; 97, 3% Greek nationality Secondary school children from urban areas of Athens and Crete	Questions on health education topics; Access and source of health information (seeking); Stated satisfaction	n.a. no information on specific items is available	n.a.	n.a	n.a.
7	Schmidt et al., 2010 [43] Germany German	GeKoKids Questionnaire New instrument	Mixed approach	To elaborate a set of short scales to measure important health literacy domains in children; and To analyse their associations among each other	N = 852; aged 9–13 y., Germany n = 401 female n = 451 male n = 29 migration background Secondary school	Knowledge; Attitudes; Communication; Behaviour; Self-efficacy	17 items (provided) Knowledge: 3 items Communication: 3 items Attitude: 4 items Behaviour: 4 items Self-efficacy: 3 items	n.a.	Internal consistencies communication α = .73 attitude α = .57 Rasch analysis: Knowledge χ2 = 6.45, P = 0.17 Behaviour χ2 = 15.48, P = 0.12	n.a.
8	Wu et al., 2010 [44] Canada English	Health literacy instrument for high school students New instrument	Objective measurement/performance based assessment	Development and validation of a health literacy measurement tool for high school students in classrooms	N = 275 secondary school children 8th n = 2 9th n = 34 10th n = 202 11th n = 16 12th n = 17 48% male 52% female 69,1% other language than English at home 30,09% language English at home	Understand; Evaluate	47 items (not provided) open-ended following health related reading passages Understand: 30 items Evaluate: 17 items	n.a.	Internal consistency: α = .92	Convergent: Age, r = .17 Male gender, r = .18 Age came to Canada, r = .22 Non-English speaker, r = .15 Mother’s edu, r = .19 Father’s edu, r = .22 GPA, r = .48 Time reading/ study, r = .40 ‘fair’
9	Yu et al., 2012 [45] China Chinese	Health Literacy Questionnaire New instrument	Subjective measurement/self-report	To assess the students’ health literacy gained through school health education	N = 8008 Elementary School (n = 77) Pupils n = 4011 Middle School (n = 76) Pupils n = 3997	Knowledge; Attitude; Practice (health behaviour and lifestyle)	37 items (not provided) close-ended and open-ended	n.a.	Internal consistency: α = .0.73 Spearman-Brown coefficient 0.75	n.a.
10	Chinn et al., 2013 [49] England English	All Aspects of Health Literacy Scale (AAHLS) New instrument	Subjective measurement/self-report	To develop a health literacy instrument to use in primary care settings	N = 146 Range: 15–82 y. n = 114 female; n = 32 male Ethnicity Asian: 81 Black: 5 Mixed race: 2 White: 51 Other: 7 Healthcare setting	Functional HL; Communicative HL; Critical HL	14 items (provided) Functional: 4 items Communicative: 3 items Critical: 7 items	Approx. 7 mins.	Internal consistency: α = .75 Functional HL α = .82 Communicative HL α = .69 Critical HL α = .42	Convergent: Functional vs Communicative, r = .39 Functional vs Critical, r = .59 Communicative vs Critical, r = .19
11	Wallmann et al., 2012 [46] Germany German	Health Quiz New instrument	Objective measurement / performance based assessment	To measure and assess health knowledge as part of health literacy	N = 699 7th grade adolescents in Germany N = 375 male; n = 324 female 4 school types: Gymnasium; secondary school (n = 195), Realschule; secondary modern/intermediate school (n = 231), Gesamtschule; comprehensive school (n = 81), general school; Hauptschule (n = 192). School setting	Knowledge	49 items (partly provided) Nutrition: 7 items; Prevention: 6 items; Spare time activity (health promotion): 4 items; Human body: 32 items (12 Items health behaviour / 20 items human anatomy) Response: 4 response categories, only one right choice	20 min	n.a.	n.a.
12	Massey et al., 2013 [47] USA English	Multidimensional health literacy instrument New instrument	Subjective measurement / self-report	To develop a multidimensional health literacy instrument for adolescents concerning the health environment This study was part of a larger study that examined the effectiveness of a health literacy intervention	N = 1208 13–17 y. Mean age 14.8 y. Over 60% females Hispanic/Latino 33.7% White 22.1% Black 13.2% Asian 7.9% Other 1.9% Multi-Ethnic 20.4% Healthcare setting	(1) Patient-provider encounter; (2) Interacting with the healthcare system; (3) Rights and responsibilities; (4) Health information seeking; (5) Confidence in health information from personal source; (6) Confidence in health information from media source	24 items (provided) (1) 4 items (2) 5 items (3) 7 items (4) 3 items (5) 3 items (6) 3 items 5 point Likert scale paper and pencil or online	n.a.	Internal consistency: α = .834 Corresponding factors (related to six dimension) 1: α = .815 2: α = .803 3: α = .827 4: α = .638 5: α = .834 6: α = .709	n.a.
13	Röthlin et al., 2013 [53] Austria German	HLS-EU-Q47 and -Q16 Existing tool	Subjective measurement / self-report	To apply and validate the HLS-EU instrument in the Austrian youth population	N = 571 15 y. Female 52.7% Male 46.8% No answer 0.5% Parents born in Austria 84.1% One parent born in Austria 7% Not born in Austria 9% No setting information	Access; Understand; Appraise; Apply	47 items provided including short scale of 16 items Dichotomous response format (easy and difficult) Access: 4 items Understand: 6 items Appraise 3 items Apply: 3 items	n.a.	Internal consistency α = .90 Healthcare: α = .69 Disease prevention: α = .81 Health promotion: α = .81	Convergent: HLS-EU-Q4 and: NVS r = .09 HLS-EU-Q16 and NVS r = .14 Concurrent: HLS-EU-Q16 r = .82
14	Driessnack et al., 2014 [52] USA English	Newest Vital Sign Existing instrument	Objective measurement / performance based assessment	To explore the feasibility, utility, and validity of using the Newest Vital Sign (NVS) tool to assess health literacy in children	N = 94; N = 47 parent-child-dyads n = 47 children 7-8y, n = 18 (38%) 9-10y, n = 18 (38%) 11-12y, n = 11 (23%) Science center	Reading comprehension; Numeracy	6 items (provided) (all reading and numeracy)	Up to 3 min	Internal consistency Children α = .71 Parents α = .79	n.a.
15	Naigaga et al., 2015 [54] Uganda English and oga	Maternal Health Literacy Scale (MaHeLi scale) Short form of existing instrument	Subjective measurement/self-report	To use a short form of the validated MaHeLi scale in Uganda	N = 384 adolescent pregnant girls 15–19 y. 49% 15 y. 51% 16–19 y. 62% at least level 5 education 38% = < level 5 education Healthcare setting	Appraisal of health information (AHI); Competence and coping (CCS)	12 items (provided); Short version of MaHeLi scale	n.a.	n.a.	n.a.