184916 Measuring health literacy: Interviewer-dependent variation in literacy assessments in the REALM

Tuesday, October 28, 2008

Ian M. Bennett, MD, PhD , Family Medicine, University of Pennsylvania, Philadelphia, PA
Rosemary Frasso-Jaramillo, MS, MSPH , School of Social Policy & Practice, University of Pennsylvania, Philadelphia, PA
Irma T. Elo, PhD , Department of Sociology and Population Studies Center, University of Pennsylvania, Philadelphia, PA
Jennifer Culhane, PhD, MPH , Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, PA
Steven C. Marcus, PhD , University of Pennsylvania School of Social Policy and Practice, Philadelphia, PA
Health literacy is an important component of health communication but has not been well studied among women using the maternal-child care system. In a study of 1,034 low-income women in pregnancy and postpartum the Rapid Estimate of Adult Literacy in Medicine (REALM) was used to determine literacy. The rates of low literacy in this sample (4.8%) was approximately one quarter that expected based on demographic characteristics. We wished to determine if the commonly utilized REALM had failed.

Methods: Inter-interviewer variability was assessed in the initial sample by test of equality of variance. A sample of women was randomly selected for re-assessment of literacy using the REALM. Additionally we delivered the Short Test of Functional Health Literacy in Adults (STOFHLA) for validation.

Results: In the initial sample of 1,034 women literacy scores varied significantly with interviewer (F test, P<0.05). In the re-assessment (n=237) the distribution of literacy scores corresponded to that expected by demographic variables; 13% of the sample had low literacy (< 6th grade), 36% had marginal literacy (<7th-8th grade), and 51% had higher literacy (>9th grade). In the re-assessment the REALM and STOFHLA scores were highly correlated (74%) as expected.

Discussion: We found that in a sample of low-income women in pregnancy and postpartum the REALM assessment was unreliable. This test is widely used in the developing field of health literacy and health communication but accurate scoring is dependent on interviewer interpretation of responses. Further research is needed to determine if interviewer characteristics contribute to this variability.

Learning Objectives:
1. Describe the importance of accurately measuring health literacy in the field of health communication. 2. Recognize an important limitation of the REALM, a commonly used health literacy measure. 3. Describe the potential impact of interviewer characteristics on the reliability and validity of the REALM.

Keywords: Health Literacy, Maternal and Child Health

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have presented at APHA in the past and have given multiple educational talks and in-services. I currently teach at the University of Pennsylvania. I am working with the 1st author on a large study of literacy and Maternal Child Health as well as this project.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.