Evaluation of the REALM Health Literacy Test in a Developing Country Ros Dowse Lebo Lecoko Tina Ehlers

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Evaluation of the REALM Health Literacy Test
in a Developing CountryRos DowseLebo Lecoko
Tina Ehlers

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Introduction

• Health care systems require that patients be able
  to read
• Low-literate patients have the highest morbidity
  and mortality rates from chronic diseases and
  conditions

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Definition of health literacy

• the capacity of an individual to obtain,
  process and understand basic health information
  and services needed to make appropriate health
  decisions

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South Africa

• Verbal information PROBLEM!
• Written information PROBLEM!
• Widespread limited literacy skills
• Literacy statistics
• illiterate 45
• semi-literate 25
• literate 30
• 3 out of 4 patients problems with reading

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Measurement of health literacy

• Indirect measurement
• - standard of education
• Direct measurement
• - literacy test or task
• Valuable information
• - provide appropriately tailored medicine
  information

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REALM Test

• Health literacy test developed in USA
• Available in English
• Takes 1 3 mins to administer
• Estimates reading level below grade 9
• Consists of 3 lists of 22 words each, arranged in
  order of increasing difficulty
• Words read aloud and pronunciation checked
• Grades estimated according to number of words
  pronounced correctly

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Objective

• To evaluate the applicability of the REALM test
  in a South African English second-language
  population

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Methodology

• 125 Xhosa respondents of different educational
  levels were tested with the aid of interpreters
• All stated that they could read and understand
  English
• Demographic data obtained
• Respondents asked to read aloud as many words as
  possible from the 3 lists and then to explain
  their meaning

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Criteria for success or failure
Case Read Understand Succeeds / Fails
1 ? ? Succeeds
2 X X Succeeds
3 ? X Fails
4 X ? Fails

• Cases 1 and 2 to account for gt 80 respondents
• Apply this to gt 2/3 (44 of 66) words

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Demographics
Characteristic Number ()
Sex Male Female Age (yrs) lt 21 21 40 41 65 gt 65 Education None - Grade 3 Grades 4 6 Grades 7 8 gt Grade 9 50 (40.0) 75 (60.0) 6 (4.8) 65 (52.0) 51 (40.8) 3 (2.4) 30 (24.0) 30 (24.0) 30 (24.0) 35 (28.0)
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Case 3 REALM test fails
List 1 List 2 List 3
smear 58 pelvic 57 testicle 51
dose 58 menopause 62 obesity 56
incest 58 calories 71 hepatitis 59
rectal 65 irritation 62
hormones 66 constipation 64
bowel 72 anemia 73
herpes 74 inflammatory 73
impetigo 74
colitis 79
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Case 4 REALM test fails
List 1 List 2 List 3
rectal 1 fatigue 1 testicle 1
asthma 2 notify 1 emergency 1
cancer 2 directed 1 sexually 1
kidney 2 nausea 1 menstrual 2
meals 2 appendix 2 alcoholism 2
germs 2 exercise 2 diabetes 6
nerves 6 arthritis 5
eye 13 miscarriage 5
pregnancy 6
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Words which were poorly understood

• Haemorrhoids 0.0
• Colitis 0.0
• Osteoporosis 0.8
• Hepatitis 0.8
• Inflammatory 1.6
• Seizure 1.6
• Anemia 2.4
• Menopause 4.0

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REALM TestAccept / Reject?

• REALM test only worked for 8 of the 66 words
• It failed in 41 of a total of 8250 cases (125
  respondents x 66 words)

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Conclusion

• REALM test is not a suitable tool to assess
  health literacy in this population
• Ability to pronounce words gives no indication of
  comprehension
• Schooling is an unreliable literacy marker
• Enables suitable terms to be identified for
  inclusion in patient information leaflets

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Acknowledgements

• Rhodes University for financial support
• Professor Radloff for assistance with statistics
• Interpreters and respondents who contributed to
  this project