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