Evaluation of the REALM
Health Literacy Test in a
Developing Country
Ros Dowse
Lebo Lecoko
Tina Ehlers
FIP September 2002
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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
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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
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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
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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 > 80%
respondents
 Apply this to > 2/3 (44 of 66) words
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Demographics
Characteristic
Sex:
Age (yrs):
Education:
Male
Female
< 21
21 – 40
41 – 65
> 65
None - Grade 3
Grades 4 – 6
Grades 7 – 8
> Grade 9
Number (%)
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50
75
6
65
51
3
30
30
30
35
(40.0)
(60.0)
(4.8)
(52.0)
(40.8)
(2.4)
(24.0)
(24.0)
(24.0)
(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
pregnancy
5%
6%
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Words which were poorly understood:
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Haemorrhoids
Colitis
Osteoporosis
Hepatitis
Inflammatory
Seizure
Anemia
Menopause
0.0%
0.0%
0.8%
0.8%
1.6%
1.6%
2.4%
4.0%
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REALM Test
Accept / 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
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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
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