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Development and Validation of a Short-Form, Rapid Estimate of Adult Literacy in Medicine

Arozullah, Ahsan M. MD, MPH*†; Yarnold, Paul R. PhD; Bennett, Charles L. MD, PhD, MPP*‡; Soltysik, Robert C. MS*; Wolf, Michael S. PhD, MPH; Ferreira, Rosario M. MD, MPP*‡; Lee, Shoou-Yih D. PhD§; Costello, Stacey BA*; Shakir, Adil MBBS*; Denwood, Caroline BA*; Bryant, Fred B. PhD; Davis, Terry PhD

doi: 10.1097/MLR.0b013e3180616c1b
Original Article

Background: Although prior studies used the 66-item Rapid Estimate of Adult Literacy in Medicine (REALM instrument) for literacy assessment, researchers may require a shorter, validated instrument when designing interventions for clinical contexts.

Objective: To develop and validate a very brief literacy assessment tool, the REALM-Short Form (REALM-SF).

Patients: The model development, validation, and field testing validation samples included 1336, 164, and 50 patients, respectively.

Setting: General medicine and subspecialty clinics and medicine inpatient wards.

Design: For development and validation samples, indicator variables for REALM instrument items were evaluated as potential predictors of REALM instrument score by stepwise multiple regression analysis with subsequent bootstrap and confirmatory factor analysis of selected items. Pearson correlations compared REALM-SF and REALM instrument scores and kappa analyses compared grade level assignments. For the field testing validation sample, Pearson correlations compared Wide Range Achievement Test and REALM-SF scores.

Results: The REALM-SF included 7 items with stable model coefficients and 1 underlying linear factor. REALM-SF and REALM instrument scores were highly correlated in development (r = 0.95, P < 0.001) and validation (r = 0.94, P < 0.001) samples. There was excellent agreement between REALM-SF and REALM instrument grade-level assignments when dichotomized at the 6th grade (development: 97% agreement, K = 0.88, P < 0.001; validation: 88% agreement, K = 0.75, P < 0.001) and 8th grade levels (development: 94% agreement, K = 0.78, P < 0.001; validation: 84% agreement, K = 0.67, P < 0.001). REALM-SF and Wide Range Achievement Test scores were highly correlated (r = 0.83, P < 0.001) in field testing validation.

Conclusions: The REALM-SF provides researchers a brief, validated instrument for assessing patient literacy in diverse research settings.

From the *Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois, and the VA Center for the Management of Complex Chronic Care (CMC3), Hines, Illinois; †Sections of General Internal Medicine and Health Promotion Research of the Department of Medicine, University of Illinois at Chicago, Chicago, Illinois; ‡Divisions of Emergency Medicine, Hematology/Oncology, General Internal Medicine, and Gastroenterology of the Department of Medicine, Feinberg Medical School of Northwestern University, Chicago, Illinois; §Department of Health Policy Administration, University of North Carolina, Chapel Hill, North Carolina; ¶Department of Psychology, Loyola University, Chicago, Illinois; and ∥Departments of Medicine and Pediatrics, Louisiana State University Health Sciences Center, Shreveport, Louisiana.

Drs Arozullah and Ferreira were supported as Research Associates in the Career Development Award Program of the Veterans Affairs Health Services Research and Development Service. This project was supported through a Pfizer Health Literacy Grant. Dr. Lee's participation was partially supported by a research grant from the Agency for Healthcare Research and Quality (R01 HS13004).

The sponsors (VA, Pfizer, AHRQ) had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Preliminary results of this manuscript were presented as an oral abstract presentation at the American Society of Clinical Oncology 2004 Annual Meeting held in New Orleans, Louisiana.

Reprints: Ahsan M. Arozullah, MD, MPH, Research and Development, Room 6203, Jesse Brown VA Medical Center (151), 820 S. Damen Avenue, Chicago, IL 60612. E-mail:

© 2007 Lippincott Williams & Wilkins, Inc.