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After obtaining informed consent, trained interviewersassessed each patient’s health literacy level usingthe REALM, an instrument used to estimate healthliteracy by measuring reading ability through medicalword recognition. In the REALM, the patient is giventhree lists, each containing 22 medical words arrangedin order of difficulty and asked to read each word aloud.The REALM score is the total number of correctlypronounced words for the three lists, ranging from 0 to66. REALM scores are objective and correlate highly(r=0.88 to 0.97) with standardized reading tests.28Examples of words listed on the REALM are “infection”and “diabetes.” The range of REALM scores iscategorized into three literacy levels: inadequate (at orbelow sixth grade), marginal (seventh to eighth grade)and adequate (at or above ninth grade
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