Rapid Estimate of Adult Literacy in Medicine revised, shorter version (REALM-R)
Rapid Estimate of Adult Literacy in Medicine: revised, shorter version (REALM-R).
Description of the Test
The REALM-R is a brief screening instrument used to assess an adult patient’s ability to read common medical words. It is designed to assist medical professionals in identifying patients at risk for poor literacy skills. The REALM-R is a word recognition test – not a reading comprehension instrument. Adults are asked to de-code or pronounce words. The test takes less than 2 minutes to administer and score.
Preliminary data regarding the REALM-R has been published in the Journal of General Internal Medicine December 2003; 18:1036-1038.
Administration and Scoring:
1. Give the patient the laminated copy of the REALM-R word list. Attach the examiner record form to the clipboard. Hold the clipboard at an angle such that the patient is not distracted by your scoring procedure.
In your own words, introduce the REALM-R to the patient:
In a research setting or for research purposes:
"It would be helpful for us to get an idea of what medical words you are familiar with. What I need you to do is look at this list of words, beginning here [point to first word with pencil]. Say all of the words you know. If you come to a word you don’t know, you can sound it out or just skip it and go on."
If the patient stops, say, "Look down this list [point] and say the other words you know."
In a clinical setting:
"Sometimes in this office, we may use medical words that patients aren’t familiar with. We would like you to take a look at this list of words to help us get an idea of what medical words you are familiar with. It will help us know what kinds of patient education to give you. Start with the first word [point to 1st word with pencil], please say all of the words you know. If you come to a word you do not know, you can sound it out or just skip it and go on." If patient stops do as above.
**Special Note: Do not use the words "read" and "test" when introducing and administering the REALM-R. These words may make patients feel uncomfortable and unwilling to participate.
"Please say these words for me?"
"Let’s try the next word."
If the patient begins to miss every word or appears to be struggling or frustrated, tell the patient,
"Just look down the list and say the words you know."
3. Count as an error any word that is not attempted or mispronounced (see "Special Considerations" for pronunciation/scoring guidelines).
4. Scoring options:
1) Place a check mark on the line next to each word the patient pronounces correctly.
2) Place an X on the line next to each word the patient does not attempt or mispronounces.
Scoring should be strict, but take into consideration any problems which could be related to dialect or articulation difficulties. Use the dictionary if in doubt. Count as correct any self-corrected word. In our study we chose to define ‘at risk patients’ as those with a score of six or less.
Special Considerations for Administration and Scoring:
Many low literate patients will attempt to hide their deficiency. Ensure that you approach each patient with respect and compassion. You may need to provide encouragement and reassurance.
A positive, respectful attitude is essential for all examiners. (Remember, many people with low literacy feel ashamed.) Be sensitive.
If the patient wears glasses, ask him/her to put them on for this test. The REALM-R is designed to be read by persons with 20/100 vision or better. For vision of 20/100 or better I have used a font size of 18. In my studies we have excluded patients with worse vision. The REALM has a visually impaired version using a font size of 28.
Dictionary pronunciation is the scoring standard.
Dialect, Accent or Articulation Problems:
Count a word as correct if the word is pronounced correctly and no additions or deletions have been made to the beginning or ending of the word. For example: A patient who says "jaundiced" would not receive credit for the word "jaundice"; "directs" would not receive credit for the word "directed"; "colon" would not receive credit for "colitis". Words pronounced with a dialect or accent should be counted as correct provided there are no additions or deletions to the word. Particular attention should be paid for patients who use English as a second language.
REALM-R Examiner Record
|______________||Date of Birth:||______________||Grade
|Fat, Flu, and Pill are not scored. We have previously used a score of 6 or less to identify patients at risk for poor literacy.|