Development and Testing of the Test of Functional Health Literacy in Dentistry (TOFHLiD)


  • This research was conducted with the support of the UNC Short-Term Research Fellowship, AADR Bloc Travel Grant, NIDCR Grant #1K22DE14743, and MCHB #5T17MC00015-140. Abstract presented as an oral presentation in March 1705 at the IADR/AADR/CADR 83rd General Session and Exhibition in Baltimore, MD.

Jessica Y. Lee, DDS, MPH, PhD, Department of Pediatric Dentistry CB 7450, University of North Carolina, Chapel Hill, NC 27599-7450. Tel.: 919-966-2739; Fax: 919-966-7992; e-mail:


Objective: This study aims to evaluate the reliability and validity of the Test of Functional Health Literacy in Dentistry (TOFHLiD), a new instrument to measure functional oral health literacy.

Methods: TOFHLiD uses text passages and prompts related to fluoride use and access to care to assess reading comprehension and numerical ability. Parents of pediatric dental patients (n=102) were administered TOFHLiD, a medical literacy comprehension test (TOFHLA), and two word recognition tests [Rapid Estimate of Adult Literacy in Dentistry (REALD), Rapid Estimate of Adult Literacy in Medicine (REALM)]. This design provided assessments of dental and medical health literacy by all subjects, both measured with two different methods (reading/numeracy ability and word recognition). Construct validity of TOFHLiD was assessed by entering the correlation coefficients for all pairwise comparisons of literacy instruments into a multitrait-multimethod matrix. Internal reliability of TOFHLiD was assessed with Cronbach’s alpha. Criterion-related predictive validity was tested by associations between the TOFHLiD scores and the three measures of oral health in multivariate regression analyses.

Results: The correlation coefficient for TOFHLiD and REALD-99 scores (monotrait-heteromethod) was high (r=0.82, P < 0.05). Coefficients between TOFHLiD and TOFHLA (heterotrait-monomethod: r=0.52) and REALM (heterotrait-heteromethod: r=0.53) were smaller than coefficients for convergent validity. Cronbach’s alpha for TOFHLiD was 0.63. TOFHLiD was positively correlated with OHIP-14 (P < 0.05), but not with parent or child oral health. TOFHLA was not related to dental outcomes.

Conclusions: TOFHLiD demonstrates good convergent validity but only moderate ability to discriminate between dental and medical health literacy. Its predictive validity is only partially established, and internal consistency just meets the threshold for acceptability. Results provide solid support for more research, but not widespread use in clinical or public health practice.