Applicability of the REALM health literacy test to an English second-language South African population

Objective and setting To investigate health literacy in an English second language population using the REALM test, to evaluate its appropriateness and to compare health literacy between four different education categories. Setting Primary healthcare clinics and participant homes in Grahamstown, South Africa. Method The REALM test, a US-developed test, was administered via an interpreter to 125 Xhosa-speaking, English second language participants from a range of educational backgrounds. Participants were asked to read all 66 words (three lists of 22 words each), and pronunciation was assessed. In a deviation from the standard method, an explanation for each word was requested to evaluate comprehension. Results were classified into four categories: adequately pronounced and comprehended; neither adequately pronounced nor comprehended; adequately pronounced but not comprehended; not adequately pronounced but comprehended. The first two categories were rated as applicable. The percentage of applicable cases of the total of 8250 cases (125 participants; 66 words each) was calculated. The association between education and both pronunciation and comprehension was investigated using chi-square tests, with a significance level of P < 0.05. Main outcome measures: Average grade-equivalent reading level; number of words adequately pronounced and comprehended; applicability of the REALM to individual words. Results Average grade-equivalent reading level of the study population according to the REALM test was grade 7-8. An average of 46 of 66 words were adequately pronounced, whereas less than half this number (20) were adequately comprehended. Comprehension ability was 57% lower than the ability to adequately pronounce the words, a finding that highlights the inability of pronunciation data to predict comprehension of a health-related text. Examples of poor comprehension include antibiotics (16.0%), fatigue (6.4%), nausea (8.0%), anaemia (2.4%), osteoporosis (0.8%), hepatitis (0.8%), haemorrhoids (0%), impetigo (0%) and colitis (0%). Both pronunciation (P = 0.016) and comprehension (P = 0.001) were significantly influenced by education. Applicability of the REALM to individual words ranged from 20.8 to 96.0%, with an average of 59.1%. Given that the REALM was deemed inapplicable for an average of four out of every 10 words, it appears to be unsuitable for use in its current form for assessing health literacy of the study population.