1. FIP September 20021 Evaluation of the REALM Health Literacy Test in a Developing Country Ros Dowse Lebo Lecoko Tina Ehlers

2. FIP September 20022 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

3. FIP September 20023 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”

4. FIP September 20024 South Africa Verbal information……… PROBLEM! Written information……… PROBLEM! Widespread limited literacy skills Literacy statistics: illiterate45% semi-literate 25% literate 30% 3 out of 4 patients – problems with reading

5. FIP September 20025 Measurement of health literacy Indirect measurement - standard of education Direct measurement - literacy test or task Valuable information - provide appropriately tailored medicine information

6. FIP September 20026 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

7. FIP September 20027 Objective To evaluate the applicability of the REALM test in a South African English second-language population

8. FIP September 20028 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

9. FIP September 20029 Criteria for success or failure Cases 1 and 2 to account for > 80% respondents Apply this to > 2/3 (44 of 66) words CaseReadUnderstand Succeeds / Fails 1 Succeeds 2XX 3 X Fails 4X Fails

10. FIP September 200210 Demographics CharacteristicNumber (%) Sex:Male Female Age (yrs):< 21 21 – 40 41 – 65 > 65 Education:None - Grade 3 Grades 4 – 6 Grades 7 – 8 > Grade 9 50 (40.0) 75 (60.0) 6 (4.8) 65 (52.0) 51 (40.8) 3 (2.4) 30 (24.0) 35 (28.0)

11. FIP September 200211 Case 3 – REALM test fails List 1 List 2 List 3 smear 58% pelvic 57% testicle51% dose58% menopause 62% obesity56% incest58% calories 71% hepatitis59% rectal65% irritation62% hormones66% constipation64% bowel72% anemia73% herpes74% inflammatory73% impetigo74% colitis79%

12. FIP September 200212 Case 4 – REALM test fails List 1 List 2 List 3 rectal 1% fatigue1% testicle1% asthma2% notify1% emergency1% cancer2% directed1% sexually1% kidney2% nausea1% menstrual2% meals2% appendix2% alcoholism2% germs2% exercise2% diabetes6% nerves6% arthritis5% eye13% miscarriage5% pregnancy6%

13. FIP September 200213 Words which were poorly understood: Haemorrhoids0.0% Colitis0.0% Osteoporosis0.8% Hepatitis0.8% Inflammatory1.6% Seizure1.6% Anemia2.4% Menopause4.0%

14. FIP September 200214 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)

15. FIP September 200215 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

16. FIP September 200216 Acknowledgements Rhodes University for financial support Professor Radloff for assistance with statistics Interpreters and respondents who contributed to this project