Health literacy—Adolescent health literacy is assessed using
the Rapid Estimate of Adult Literacy in Medicine, teen version
(REALM-Teen) [21] which was validated in teens ages 10 to 19 and
correlates with measures of general literacy and with health
behaviors known to be associated with health literacy. This
interviewer-administered tool requires respondents to read a list
of 66 health-related terms. Scoring is based on the number of items
correctly read. While the REALM does not comprehensively
measure the construct of health literacy, research in teens and
in adults has found high correlations been between it and the Test
of Functional Health Literacy in Adults (TOFHLA), a longer, more
comprehensive (often considered ‘‘gold-standard’’) tool that
measures understanding of words in context [44,45]. For our
analyses health literacy is dichotomized as LOW—below 8th grade
equivalent (REALM-teen score < = 58) and HIGH—8th grade
equivalent or higher (REALM-Teen score > = 59). This cut point
was chosen so that all persons classified as low actually scored
below their current grade level.