Internal consistency of the Spanish health literacy test (TOFHLA-SPR) for Puerto Rico.
Abstract: Background: Low functional health literacy has been related to poor viral control, and lower levels of ART adherence in people living with HIV/AIDS. Research in functional health literacy among people living with HIV/AIDS in Puerto Rico (PR) is an unexplored area. The purpose of this paper is to describe how the full-length Spanish Version of the Test of Functional Health Literacy in Adults (TOFHLA-S) scale was adapted to PR.

Methods: Thirty participants (women = 16, men = 14) completed a basic demographic questionnaire, the TOFHLA-S and participated in an interview. Analyses were performed to examine the information provided by participants and the internal consistency of the TOFHLA-S.

Results: The mean age was 47.7 years (range 34-77). Thirty-seven percent had less than 12 years of formal schooling and 43% reported having education above high school. Changes suggested by participants included: increasing font size from 14 to 16 points for better readability and changes/simplification of several words in order to make them colloquial and comprehensible for the PR context. The reliability coefficient obtained for this scale was strong (estimated alpha = 0.95) however, differences were observed by subtype: numeracy (estimated [alpha.sub.num] = .819 vs. comprehension (estimated alpha =. 953).

Conclusions: Based on this process, we have adapted the original version of the TOFHLA-S and the new version of the full-length TOFHLA-S, PR is now valid for further research and testing levels of functional health literacy in a larger sample in PR. [P R Health Sci J 2010;1:49-53]

Key words: TOFHLA-SPR, Internal consistency, HIV/AIDS, Puerto Rico

Antecedentes: La baja literacia funcional de la salud ha sido relacionada a pobre control viral y bajos niveles de adherencia a terapia antirretroviral en personas que viven con VIH/SIDA.

En Puerto Rico (PR), no existen estudios relacionados a la literacia funcional de la salud en esta poblacion. El proposito de este manuscrito es describir la adaptacion de la version larga en espanol de la Prueba de Literacia Funcional de la Salud en Adultos (TOFHLA-S) a PR. Metodos: Treinta participantes (mujeres = 16, hombres = 14) completaron un cuestionario demografico basico, el TOFHLA-S y participaron en una entrevista. Se analizo la informacion provista por los participantes al igual que la consistencia interna del TOFHLA- S.

Resultados: La media de edad fue 47.7 anos (rango 34-77). Un 37% de la muestra tenia menos de 12 anos de escolaridad formal y un 43% reporto tener una educacion superior al nivel de escuela superior. Cambios sugeridos por los participantes incluyeron: aumentar el tamano de la letra de 14 a 16 puntos y algunos cambios a palabras para que fuesen mas sencillas, coloquiales y comprensibles para el contexto de PR. La confiabilidad obtenida fue fuerte (estimated [alpha.sub.num] = 0.95) no obstante, se observaron diferencias por subtipos: numeracia (estimated [alpha.sub.num] = .819) vs. comprension (estimated alpha = .953). Conclusiones: Basandose en este proceso, hemos adaptado la version original larga del TOFHLA-S y ahora el TOFHLA-S, PR es valido para medir niveles de literacia funcional de la salud en una poblacion de PR mas extensa.
Article Type: Perspectiva general de la enfermedad/trastorno
Subject: Pacientes del SIDA (Investigacion cientifica)
Pacientes del SIDA (Analisis de casos)
Pacientes del SIDA (Cuidado y tratamiento)
Authors: Rivero-Mendez, Marta
Suarez, Erick
Solis-Baez, Solymar S.
Hernandez, Gloryvee
Cordero, Wanda
Vazquez, Irma
Medina, Zullettevy
Padilla, Raisa
Flores, Aida
Bonilla, Jose Luis
Holzemer, William L.
Pub Date: 03/01/2010
Publication: Name: Puerto Rico Health Sciences Journal Publisher: Universidad de Puerto Rico, Recinto de Ciencias Medicas Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Universidad de Puerto Rico, Recinto de Ciencias Medicas ISSN: 0738-0658
Issue: Date: March, 2010 Source Volume: 29 Source Issue: 1
Geographic: Geographic Name: Puerto Rico
Accession Number: 219519249
Full Text: Inn recent years, functional health literacy has been recognized as an extremely important issue of care management of people living with HIV/AIDS (1-2). There is evidence that suggests that the level of functional health literacy in people with HIV/AIDS determines medication adherence, symptoms and symptoms management strategies (3-5). Low functional health literacy has been related to poor viral control, and lower levels of ART adherence (5). Although the problem of health literacy is not exclusive to people living with HIV/AIDS and minority groups, health literacy is frequently below functional levels in this population resulting in a potential difficulty in accessing care or understanding and maintaining self-care behaviors that will result in sustained or improved health status and quality of life (5).

In the year 2000, the U.S. Census Bureau reported that in Puerto Rico (PR) the literacy rate, measured by the ability to read and write, was 94.1% for both genders. Although Census data seems to reflect adequate levels of literacy for Puerto Rican people, this is only a quantitative traditional measure that does not provide an accurate portrait of the functional nature of health literacy that has been demonstrated to be a key determinant of people's health. What is considered literacy levels has evolved and is currently viewed as an advancing or developing set of reading and number skills, knowledge, and strategies that people build on throughout their lives for functioning in different contexts (6). In the health care environment, functional health literacy accounts for a person's capabilities to obtain, process, and understand basic health information needed for functioning and making appropriate health care decisions (7-9). People living with HIV/AIDS need functional health literacy to understand and comprehend concepts of quantity, time, and risk. A consensus is developing that low or limited health literacy exposes people to adverse outcomes such as poorer self-management of chronic diseases, less healthy behaviors, higher rates of hospitalizations, and overall poorer health, which in turn increases health disparities (10-13).

Research in functional health literacy among people living with HIV/AIDS in PR is an unexplored area. Because most of the health literacy studies were developed on the mainland United States, not much is known in our population. The measurement process of functional health literacy requires the use ofreliable and valid assessment tools for Puerto Rican people living with HIV/AIDS. The full-length Spanish version of the Test of Functional Health Literacy in Adults (TOFHLA-S) (14) has been described in the literature and used on different populations and health conditions to assess a patient's ability to read health related materials. Although the TOFHLA-S has been used with persons with HIV/AIDS (1, 4) and tested with Latino populations in the United States (15) at this point it has not been used and validated with people living with HIV/AIDS in the PR context.

This paper describes how the full-length TOFHLA-S scale was adapted to PR in a sample of people living with HIV/AIDS infection and assessed its internal consistency by using the Cronbach's alpha coefficient.



A convenience sample of 30 Puerto Rican participants living with HIV/AIDS, balanced by gender, were selected from a state ambulatory clinic located in the Metropolitan area of San Juan serving almost 2,000 people with HIV/AIDS from a broad socio-demographic range. The inclusion criteria included: diagnosis of HIV/AIDS (confirmation determined by self-report of the participant), adult, all genders (men and women, transgender) as defined by the participant, self-reporting symptoms, may or may not be pregnant, and able to read and understand Spanish.

Exclusion was based on the following criteria: documented diagnosis of dementia, unable to understand consent procedure as judged by the person obtaining consent, self-reporting no symptoms, unable to read or understand Spanish, self-reporting not receiving ART, blindness or being too ill to participate.

Authorization to conduct the study was obtained from the Institutional Review Board of the University of Puerto Rico, Medical Sciences Campus. Participants received information about the purpose of the study and their rights to withdraw from the study at any time. Data collection was held during convenient times at the setting where participants received services and where confidentiality and privacy conditions could be assured.


1) Demographic Survey - a 20 item self-report survey assessed participant's gender, HIV status, marital status, and other demographic variables.

2) The TOFHLA-S is a survey questionnaire that uses actual medical documents to evaluate individual's numerical and reading comprehension, two components that are considered necessary to accurately follow instructions that are commonly encountered when seeking health care services, including prescription container labels and discharge instructions. Although a short version of the TOFHLA is available, this study used the full-length Spanish version in order to collect more information about the person's level of functioning, not possible with the short version. Part 1 is a 17-item test for numeracy (numbers) using actual hospital forms and labels for prescription vials. Part 2 is a 50-item test for reading comprehension and is based on the Cloze method in which participants read passages of text about medical topics in which every fifth to seventh word is omitted. The participants must fill in the blank spaces using words selected from the four multiple choice list options provided for each space, identifying the words most appropriate to the context of the passage. It takes approximately 10-20 minutes to complete (14). The TOFHLA-S is scored on a scale of 0-100 scores, with higher scores 75-100 indicating adequate functional health literacy, scores between 60-74 indicating marginal literacy, and scores of 0- 59 or below indicating inadequate functional health literacy. In early developmental studies, the original full length version of the TOFHLA-S was reported to be a valid and reliable measure to evaluate functional health literacy. Adequate Cronbach's Alpha has been obtained for the total TOFHLA-S with .98, for numeracy .84, and reading comprehension with .98 (14).


The TOFHLA-S was evaluated for cultural equivalence for our population using Beaton et al., (16) guidelines. This process was conducted in four phases. First, the research team was trained on how to enroll, interview and administer the TOFHLA-S to participants. To verify that research team members understood how to properly administer the TOFHLA-S, they administered the test to one another and their performance was evaluated by the project director. Second, participants completed a basic demographic questionnaire which gathered information about characteristics such as age, race, gender, education, income, work status, years with HIV, CD4 count, and viral load. Third, participants completed the TOFHLA-S. The numeracy component uses a series of prompts to which participants respond. These prompts consist of: prescription vials, an appointment slip, a chart describing eligibility for financial aid, and example of results from medical test (14). Responses were coded dichotomously as correct or incorrect. Fourth, participants completed the reading comprehension tests. Passages covered themes that included instructions for preparation for an upper GI series, the patient rights and responsibilities section of a Medicaid application form, and a standard hospital informed consent (14). Data was also collected on how long the participants took to complete the

TOFHLA-S survey.

A fifteen-minute interview was then conducted with each participant and they were encouraged to talk about what they thought was meant by each item, the clarity, font size, relevance, wording, understanding, and ease of completion of the items and the instrument as a whole. After completing the TOFHLA-S, each participant received a mo netary incentive to cover food and transportation costs. Codes and identification numbers were created for each subject so that confidentiality was maintained throughout their participation.

Data Analysis

Responses to the survey were entered into Statistical Software STATA Version 10 (17). To describe the study group several statistics were computed (mean, standard deviations, frequency, and percent). Analyses were also performed to examine the internal consistency (alpha coefficients) of the TOFHLA-S, overall and by subtypes (numeracy and comprehension) and sex. According to Houser (18) criteria for the Cronbach's alpha should exceed a value of 0.7 for the instrument to be considered reliable.


Thirty Puerto Rican participants comprised the sample including 16 women and 14 men. The mean age was 47.7 years (range of 34-77) with a standard deviation of 10.30.

Thirty-seven percent had less than 12 years of formal schooling, 20% had a high-school education, and 43% reported having education above high school (Table 1). The mean response time to complete the entire TOFHLA-S test was 20 minutes and 11 seconds. In the numeracy component, the mean response time was 8:43 minutes and for the reading comprehension component the mean was 11.68 minutes. Changes suggested by participants included an increasing of the survey letters from 14 to 16 point font for better readability. Dates on pill bottles were updated as requested by participants to reflect the current year. Additionally, semantic equivalence was used and changes were made on several words to make them more simple, colloquial and comprehensible for the participants in the PR context (Table 2). For example in numeracy, "lunch" (prompt 8) was translated in Spanish in the original TOFHLA-S as "comida". "Comida "in the PR context is usually the last meal of the day. Since the prompt was related to lunch, participants recommended substituting the word "comida" for "almuerzo", whose meaning in PR is lunch. In the reading comprehension component, five words (mandado, Rayos X, taciturno, condado, and TANF/ Welfare") were also changed for better comprehension (Table 2). The word "condado" was changed to municipio and the acronym "TANF/Welfare", which was left in English in the Spanish version of the TOFHLA, was changed as suggested by participants (Table 2). The original TOFHLA-S revealed no major problems or language difficulties.

Consistent with prior studies, we found that the total literacy score for males was 71.4%, while in female this proportion was reduced to 43.8% (19). Comparison of TOFHLA-S scores by sex is showed on Table 3. The scale reliability coefficient obtained for this scale was strong (estimated alpha = 0.95) however, differences were observed by subtype: numeracy (estimated [alpha.sub.num] = .819) vs. comprehension (estimated alpha = .953).


These findings support the need to tailor instruments within a language and to different contexts, which would make the instrument unique because it would take into account the cultural nuances of that language. The TOFHLA-S required editing so that the meanings of the words were equivalent, even though the actual words were changed. This study shows that the full length TOFHLA-S scale exhibited strong consistency with the original version. Although it has been tested with Hispanic/Latino populations living with HIV/AIDS in the United States, this is the first investigation in PR that assesses the internal consistency of this Spanish scale. There were few changes suggested by participants on the full-length Spanish version to improve mostly semantic equivalence. Based on this process, we have adapted the original version of the TOFHLA-S and the new version TOFHLA-S, PR is now valid for further research in testing levels of functional health literacy in a larger sample of people living with HIV/ AIDS in PR.


We gratefully acknowledge SIDA San Juan clinic and the employees Blanca Gonzalez Acre RN, MSN and Dr. Lester Rosario, for their help in the recruitment of participants in their clinical setting. We also thank all of the people who willingly gave their time and participated in the study. This project was supported by Award Number R15NR011130 from the National Institute of Nursing Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Nursing Research or the National Institutes of Health.


(1.) Kalichman SC, Benotsch EG, Suarez T, Catz SL, et al. Health Literacy and health-related knowledge among men and women living with HIV-AIDS. Am J Prev Med 2000;18:325-331.

(2.) Benotsch EG, Kalichman S, Weinhardt, LS. HIV-AIDS Patients' evaluation of health information on the internet: The digital divide and vulnerability to fraudulent claims. J Consult Clin Psychol 2004;7296: 1004-1011.

(3.) Wolf MS, Davis TC, Arozullah A, Penn R. et al.; Relation between literacy and HIV treatment knowledge among patients on HAART regimens. AIDS Care 2005;17:863-873.

(4.) Kalichman SS, Rompa D. Functional health literacy is associated with health status and health related knowledge in people living with HIV/ AIDS. J Acquir Immune Defic Syndr 2000;25:337-344.

(5.) Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Inter Med 1999;14:267-273.

(6.) Kirsch I. The International adult literacy survey (IALS): Understanding what was measured. Educational Testing Service. 2001; Research Report RR-01-25.

(7.) Speros C. Health literacy: Concept analysis. J Adv Nurs 2005;50: 633-640.

(8.) Pasasche-Orlow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, et al. The prevalence of health literacy. J Gen Inter Med 2004;20:175-184.

(9.) American Medical Association. Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs. JAMA 1999;281:552-557.

(10.) Wallance L. Patient' health literacy skills: The missing demographic variable in primary care research. NAPCRG Newsletter 2006;34:1-2.

(11.) DeWalt DA, Berkman ND, Sheridan S, Lohr KN, et al. Literacy and Health Outcomes: A systematic review of literature. J Gen Inter Med 2004;19:1228-1239.

(12.) Fisher WJ. The crucial link between literacy and health. American College of Physicians 2003;139:875-878.

(13.) Kefalides PT. Illiteracy: The silent barrier to health care. Ann Intern Med 1999;130:333-336.

(14.) Nurss JR, Parker RM, Baker DW. TOFHLA: Test of functional health literacy in adults. Peppercorn Books and Press, Inc, 1995.

(15.) Parker RM, Baker DW, Williams MV, et al.; The test of functional health literacy in adults; a new instrument for measuring patients' literacy skills. J Gen Inter Med 1995;10:537-541.

(16.) Beaton D, Bombardier C, Guillemin F, Bosi-Ferraz MB. Recommendations for cross-cultural adaptation of health measures. American Academy of Orthopaedic Surgeons Institute for Work and Health 2002; 1-34.

(17.) Stata Corp. Stata Statistical Software: Release 10. College Station, TX: StataCorp LP. 2007.

(18.) Houser J. Nursing research: Reading, using, and creating evidence. Jones & Barlett Publisher, Inc.1st ed. Boston, 2008: p. 252-253.

(19.) Waldrop-Valverde D, Jones DL, Jayaweeva D, Gonzalez P, Romero J, Ownby RL. Gender differences in medication management capacity in HIV infection: The role of health literacy and numeracy. AIDS Behav 2009;13:46-52.

Marta Rivero-Mendez, RN, DNS *; Erick Suarez, Ph D [[dagger]]; Solymar S. Solis-Baez, Ph D(c) *; Gloryvee Hernandez, RN, MSN *; Wanda Cordero, RN, MSN *; Irma Vazquez, BSN [[double dagger]]; Zullettevy Medina, BSN [[double dagger]]; Raisa Padilla, BSN [[double dagger]]; Aida Flores, BSN [[double dagger]]; Jose Luis Bonilla, BSN [[double dagger]]; William L. Holzemer, RN, Ph D, FAAN [[section]]

* School of Nursing, [[dagger]] School of Public Health, and [[double dagger]] Student of School of Nursing, University of Puerto Rico Medical Sciences Campus; [[section]] University of California, San Francisco, School of Nursing

Address correspondence to: Marta Rivero-Mendez, RN, DNS, Professor, University of Puerto Rico Medical Sciences Campus, School of Nursing, P.O. Box 365067, San Juan, PR 00936-5067. Tel: (787) 620-8439 * Fax: (787) 281-0721 * Email : marta.
Table 1. Socio-demographic characteristics of participants (n = 30)

Sex                            n              %

  Women                        16             53.3%
  Men                          14             46.7%

Age                                   [bar.x] = 47.7 (SD = 10.30)
                                      Range: 34-77
  Less than 9th grade          11             37%
  High school                  6              20%
Above high school              13             43%
Prevalence of Co-morbidities
  Hepatitis C                  7/30 = 23.3%
  Hypertension                 6/30 = 20.0%
  Depression                   5/30 = 16.7%
  Diabetes                     4/30 = 13.3%
  Asthma                       3/30 = 10.0%

Table 2. Recommendations from participants in numeracy and reading
comprehension items

Item             Original version Item   New version item

Prompt 8         Comida (1)              Almuerzo (2)

Lecture A
1                Mandado (3)             Ordenado (4)
3                Rayos X (5)             Resultados del estudio (6)
10               Taciturno (7)           Triste (8)

Lecture B
31               Condado (9)             Municipio (10)

Lecture C
35-36            TANF/Welfare (11)       Programa de Asistencia
                                         Nutricional (12)

(1) Comida--"last meal of the day"; (2) Almuerzo--"lunch";
(3) Mandado--"request"; (4) Ordenado--"ordered"; (5) Rayos X--"X rays";
(6) Resultados del estudio--"test results"; (7) Taciturno--"taciturn";
(8) Triste--"sad"; (9) Condado--"county";
(10) Municipio--"municipality"; 11TANF/Welfare (Government Assistance
Programs); (12) Programa de Asistencia Nutricional--(Name of
Government Assistance Program in PR)

Table 3. Comparison of TOFHLA-S scores by sex

Type of Scale          Women (n=16)       Men (n=14)

  Mean (SD)            68.6 (SD = 19.9)   75.6 (SD = 19.8)
  Median               71.5               80.5
  Mean ([+ or -] SD)   30.3 (SD = 11.9)   33.3 (SD = 12.6)
  Median               37.5               36
  Mean ([+ or -] SD)   38.2 (SD = 9.9)    42.3 (SD8.7)
  Median               40                 44
Gale Copyright: Copyright 2010 Gale, Cengage Learning. All rights reserved.