Use of REALM-R vs. S-TOFHLA in an urban African American clinic population to assess health literacy: Practical implications

Low health literacy has been linked to poor health outcomes in minority communities. Subsequently, measures of health literacy have become more widely used in public health research. While the REALM-R and S-TOFHLA are common health literacy measures, their utility in urban African American clinic populations is not well documented. This paper presents results from a study with predominantly African American patients at a General Internal Medicine clinic at a large urban teaching hospital. Randomly selected adult patients were stratified to take either the REALM-R or S-TOFHLA. Results indicate very low health literacy, despite half of the population reporting high school graduation. Those taking the REALM-R were able to pronounce on average only 5 of the 11 words with 93% falling in the “low” or “very low” literacy categories. Of those taking the S-TOFHLA, the average score was a 17.9 out of 36 points, with 86.7% falling in the “inadequate” or “marginal” literacy categories. Of the two measures, the REALM-R took less time (2 minutes vs. 12-15 for the S-TOFHLA) and patients felt less threatened or confused by what was expected of them. While the S-TOFHLA results showed slightly more variation by health literacy category and identified a few individuals who would be considered to have adequate literacy compared to the REALM-R, the negativity towards the S-TOFHLA and the amount of time it took most patients to take it indicate the REALM-R is a more practical health literacy assessment to use with this population. Using socially acceptable health literacy measures is an important consideration when developing culturally appropriate research and interventions for minority populations.