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

UMMS Affiliation

Department of Quantitative Health Sciences

Publication Date


Document Type



Aged; Aged, 80 and over; Educational Status; Female; *Health Behavior; Health Education; *Health Knowledge, Attitudes, Practice; *Health Surveys; Humans; Male; Treatment Outcome; United States


Biostatistics | Epidemiology | Health Services Research


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.

DOI of Published Version



J Gen Intern Med. 2008 Oct;23(10):1561-6. Epub 2008 Jul 10. Link to article on publisher's site

Journal/Book/Conference Title

Journal of general internal medicine

PubMed ID


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Link to Article in PubMed