The Demographic Assessment for Health Literacy (DAHL): a new tool for estimating associations between health literacy and outcomes in national surveys

J Gen Intern Med. 2008 Oct;23(10):1561-6. doi: 10.1007/s11606-008-0699-5. Epub 2008 Jul 10.


Objective: To impute limited health literacy from commonly measured socio-demographic data and to compare it to the Short-Test of Functional Health Literacy in Adults (S-TOFHLA) for estimating the influence of limited health literacy on health status in the elderly.

Methods: The Prudential Medicare Study assesses the S-TOFHLA score, leading to a "reference standard" classification of 25% of people with inadequate literacy; the National Health Interview Survey has no such assessment. We estimated a regression of S-TOFHLA on sex, age, years of schooling, and race/ethnicity in The Prudential Medicare Study data to derive a Demographic Assessment for Health Literacy (DAHL) score, and imputed inadequate literacy to the 25% with the lowest DAHL scores. Using regression, we then examined associations between several health status measures (including hypertension, diabetes, physical and mental SF-12) and inadequate literacy (imputed or test-based).

Results: Estimates of association using imputed inadequate literacy closely approximate those obtained using S-TOFHLA-based inadequate literacy for most outcomes examined.

Conclusions: As few population surveys measure health literacy, the DAHL, a readily calculated health literacy proxy score, may be useful for expanding the scope of health literacy research in national survey data.

Publication types

  • Comparative Study

MeSH terms

  • Aged
  • Aged, 80 and over
  • Educational Status
  • Female
  • Health Behavior*
  • Health Education / methods
  • Health Education / standards
  • Health Education / statistics & numerical data
  • Health Knowledge, Attitudes, Practice*
  • Health Surveys*
  • Humans
  • Male
  • Treatment Outcome
  • United States / epidemiology