Rapid Estimate Of Adult Literacy In Medicine Scores Research Articles

The Health Literacy of Adults With Severe Mental Illness

The Health Literacy of Adults With Severe Mental Illness

The REALM vs. NVS: A Comparison of Health Literacy Measures in Patients with Diabetes

This study compared results of two measures of health literacy in subjects with diabetes: the Rapid Estimate of Adult Literacy in Medicine (REALM), which focuses on reading, and the Newest Vital Sign (NVS), which focuses on numeracy. The sample was predominantly white (76%), older (mean age 63 years), and female (64%). Most had at least a college education (68%). For the REALM, 83% of participants scored at a high school level of reading proficiency and 55% achieved a perfect score. Testing revealed differences in REALM score by education but not by age (education: p=0.0013; age: p=0.67). For the NVS, 55% earned scores suggesting proficiency in health numeracy and 32% earned a perfect score. Testing indicated significant differences in NVS score by both age and education (age: p=0.022; education: p=0.0017). Our results support past findings that low health-related numeracy skill is not uncommon, even among well-educated patients with adequate reading skill.

Prevalence and Demographic and Clinical Associations of Health Literacy in Patients on Maintenance Hemodialysis

Although limited health literacy is estimated to affect over 90 million Americans and is recognized as an important public health concern, there have been few studies examining this issue in patients with chronic kidney disease. We sought to characterize the prevalence of and associations of demographic and clinical characteristics with limited health literacy in patients receiving maintenance hemodialysis. As part of a prospective clinical trial of symptom management strategies in 288 patients treated with chronic hemodialysis, we assessed health literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM). We defined limited health literacy as a REALM score ≤60 and evaluated independent associations of demographic and baseline clinical characteristics with limited health literacy using multivariable logistic regression. Of the 260 patients who completed the REALM, 41 demonstrated limited health literacy. African-American race, lower educational level, and veteran status were independently associated with limited health literacy. There was no association of limited health literacy with age, gender, serologic values, dialysis adequacy, overall symptom burden, quality of life, or depression. Limited health literacy is common among patients receiving chronic hemodialysis. African-American race and socioeconomic factors are strong independent predictors of limited health literacy. These findings can help inform the design and implementation of interventions to improve health literacy in the hemodialysis population.

A Canadian exploratory study to define a measure of health literacy

This study undertook a qualitative exploration of an operational definition of health literacy and an examination of quantitative measures of health literacy skills. We interviewed 229 older Canadian adults. First we engaged them in open-ended discussions about their search for information on a self-selected health topic. Next we administered nine self-report items on health literacy skills, and then task-performance items. Task-performance questions were based on two published reading passages on five levels of difficulty to measure 'understanding' of health-related material. The Rapid Estimate of Adult Literacy in Medicine (REALM) was also administered as the comparison for criterion-related validity. Our open-ended questions elicited responses about the processes that people undergo when they attempt to access, understand, appraise and communicate health information. Qualitative findings revealed complexities in participants' interpretation of the meaning of all four health literacy skills. These descriptive findings add new knowledge about health literacy as a construct. Participants agreed with most of the self-report statements, thus indicating high belief in their own health literacy. REALM scores ranged from 45 to 66 with an average of 65 and standard deviation of 2.5. Quantitative scores on the reading passages were modestly correlated with scores on the REALM. The sum scale of self-report items, however, did not correlate with task-performance items, suggesting that the different types of items may not be measuring the same construct. We suggest that self-report items need more development and validation. Our study makes a contribution in exploring the complexities of measuring health literacy skills for general health contexts.

Health Literacy and the Provision of Information to Women with Breast Cancer

Aims Health literacy and functional health literacy are important for patients with cancer, as key information regarding treatment complications and clinical trials is often imparted using written educational material. This study measured the health literacy and functional health literacy levels in a population of women with breast cancer and compared these with the level of written information provided. Materials and methods A cross-sectional survey of women with stage I–III breast cancer attending an outpatient clinic was conducted. Health literacy levels were assessed using the Rapid Estimate of Adult Literacy in Medicine (REALM) score and functional health literacy was assessed using three validated screening questions. Patient education materials were assessed using the Simple Measure of Gobbledygook (SMOG) and Flesch Reading Ease (FRE) systems. Results One hundred and twenty-seven women were recruited. For patients, the mean REALM score was 64.3 (≥US 9th grade/reading age 14 years). The mean SMOG score of patient education materials was 80.5 (reading age 17 years). The mean FRE score of patient education materials was 55.7 (reading age 15–17 years). All patient information sheets assessed were written at ≥8th grade (reading age 13 years) and as a result up to 9% of patients would be unable to read them. Nineteen per cent of the population had inadequate functional health literacy. Conclusions Health literacy levels were high in the population studied. However, the reading level of written patient information was also high, meaning that up to 9% of patients would be unable to read the information provided. Functional health literacy levels were lower, with 19% of patients having inadequate ability. This means that although most patients are able read the information sheets provided, there is a larger proportion that would be unable to understand and act upon this information. Patient education materials should be written at an appropriate level and different modalities of communication should be used to ensure adequate comprehension.

Screening for Low Literacy in a Rheumatology Setting

The objectives of the study were to analyze literacy in 194 consecutive patients at an academic rheumatology setting with the Rapid Estimate of Adult Literacy in Medicine (REALM) and an "Arthritis-Adapted" REALM (A-REALM), and to compare responses to one another and to demographic and clinical measures. The REALM and A-REALM are two 66-item word recognition tests. Both were administered to 194 consecutive patients in usual rheumatology care. Multidimensional Health Assessment Questionnaire (MDHAQ) scores for physical function, pain, fatigue, and global estimate, and laboratory assessments also were available. Descriptive statistics and analyses of agreement were computed. REALM and A-REALM administration involved 2 to 3 minutes each. Scores below 61, indicating a reading level at eighth grade or less, were seen in 35 (18%) of 194 patients on the REALM and 46 patients (24%) on the A-REALM. No patient was classified as having severely low literacy at or below a third-grade level. However, words not read correctly by 10% or more of the patients on the REALM included diagnosis (14%), osteoporosis (17%), and inflammatory (10%), and on the A-REALM, rheumatologist (11%), cartilage (14%), and symptom (14%). REALM and A-REALM scores were correlated significantly (Pearson r = 0.94, P < 0.001). Almost all patients (33/35) with REALM scores of less than 61 also had A-REALM scores of less than 61, less formal education, and poorer clinical status on all measures, most not statistically significant. Low literacy is an important underrecognized problem in medical care, which may be assessed easily in standard care using the REALM or A-REALM. Further attention to literacy-associated barriers may reduce socioeconomic disparities in health.

Psychosocial Correlates of Health Literacy Among Older Patients With Coronary Heart Disease

This study examined psychosocial correlates of health literacy (HL) scores among older patients with coronary heart disease (CHD). A cross-sectional survey assessed psychosocial factors relating to the following: self-efficacy (i.e., perception of ability to perform a specified behavior) for diet, exercise, medication, and for a future attempt to quit smoking; social support; social stigma; appointment attendance; knowledge of heart problems; and understanding of health information. Health literacy was measured by the Rapid Estimate of Adult Literacy in Medicine (REALM). Of 321 patients, 70 had a REALM score in the low HL range (<60). When adjusting for demographics, a lower REALM score was significantly associated with reports of increased difficulty understanding health information (p < .001), less knowledge of heart problems (p = .002), increased discomfort about asking for explanations of health information (p = .014), less support with discussing health problems (p = .020). Patients with CHD and low HL are likely to face psychosocial challenges when managing their health problems. In order to encourage these individuals to seek help, health professionals need to be aware of the psychosocial characteristics of patients with low HL. These individuals may need behavioral support to increase both their self-efficacy and their understanding of their medical condition.

The association of health literacy and socio-demographic factors with medication knowledge

Objective To compare patient demographics and Rapid Estimate of Adult Literacy in Medicine (REALM) scores with respect to their ability to predict medication comprehension. Methods A survey was conducted of 100 patients presenting for follow-up at an academic primary care clinic serving a low socio-economic status population. The Medication Knowledge Score (MKS) consisted of knowledge of drug name, dose, indication, and a potential side effect for each of their medications and then averaged. The REALM (Rapid Estimate of Adult Literacy in Medicine) was administered and socio-demographic characteristics were recorded. The association of REALM score and patient characteristics with MKS was evaluated by univariate and multivariable regression analysis. Results The subjects’ mean age was 62 with an average of 9.8 years of schooling and 5.9 prescription medications. Participants identified a correct indication for 78.8% of their medications and correct dosage for 93.4%. However, they could provide the name for only 55.8% of medications and a known side effect for only 11.7%. On multivariate analysis without including REALM score, younger age ( p = .01), highest grade completed ( p = .001), and female sex ( p = .004) remained positively associated with MKS. When the model included REALM, REALM ( p < .0001), age ( p = .001), and sex ( p = .04) remained independently associated with MKS. Conclusion REALM score predicts medication knowledge as assessed by the MKS. However, age, last grade completed, and sex were also independently associated with mean MKS with a similar strength of association to that of REALM. This suggests that simpler cues to screen for medication knowledge deficits may also be useful. Since the MKS incorporates knowledge of medication indications and side effects, it may also be useful for quality and safety purposes.

Health-related vocabulary knowledge among deaf adults.

Many deaf individuals are at increased risk for fund-of-information deficits, including deficits in health-related information. Research on health information knowledge, an aspect of health literacy, demonstrates an association between low health literacy and health disparities in many populations. Deaf individuals are at particular risk for low health literacy, but no research has been conducted on this topic. To investigate health-related vocabulary knowledge in a sample of deaf adults. A task based on the Rapid Estimate of Adult Literacy in Medicine (REALM). Fifty-seven deaf adults reported whether they did or did not comprehend 66 health-related terms from the REALM. Of the participants, 81% possessed a college degree. Thirty-two percent of the deaf participants earned scores on the modified REALM task comparable to REALM scores considered indicative of low health literacy. The pattern of words that were least commonly and most commonly understood differed from normative expectations of hearing REALM respondents. This highly educated deaf participant sample demonstrated risk for low health literacy. The general deaf population is likely at even higher risk for health problems associated with low health literacy.

Development of a Word Recognition Instrument to Test Health Literacy in Dentistry: The REALD‐30 – A Brief Communication

This study aims to develop and pilot test a dental word recognition instrument. The development of our instrument was based on the Rapid Estimate of Adult Literacy in Medicine (REALM), an efficient word recognition instrument used to assess health literacy in the medical arena. Our instrument, Rapid Estimate of Adult Literacy in Dentistry (REALD-30), consisted of 30 common dental words with various degrees of difficulty. It was administered to 202 English-speaking adults recruited from outpatient medical clinics. We examined the instrument's internal reliability using Cronbach's alpha and its validity by correlating the REALD-30 score to two dental outcomes (perceived dental health status and oral health-related quality of life) and medical health literacy. REALD-30 scores were significantly correlated with REALM scores. REALD-30 was significantly related to perceived dental health status in the bivariate analysis. It also was significantly related to oral health-related quality of life in a multivariate analysis. In contrast, medical health literacy was not related to either of the dental outcome measures. The new REALD-30 instrument displays good reliability but only partial validity. Results suggest that dental health literacy may be distinct from medical health literacy and may have an independent effect on dental health outcomes.

Evaluation of a Word Recognition Instrument to Test Health Literacy in Dentistry: The REALD‐99

This study aims to evaluate a dental health literacy word recognition instrument. Based on a reading recognition test used in medicine, the Rapid Estimate of Adult Literacy in Medicine (REALM), we developed the Rapid Estimate of Adult Literacy in Dentistry (REALD-99). Parents of pediatric dental patients were recruited from local dental clinics and asked to read aloud words in both REALM and REALD-99. REALD-99 scores had a possible range of 0 (low literacy) to 99 (high literacy); REALM scores ranged from 0 to 66. Outcome measures included parents' perceived oral health for themselves and of their children, and oral health-related quality of life of the parent as measured by the short-form Oral Health Impact Profile (OHIP-14). To determine the validity, we tested bivariate correlations between REALM and REALD-99, REALM and perceived dental outcomes, and REALD-99 and perceived dental outcomes. We used ordinary least squares regression and logit models to further examine the relationship between REALD-99 and dental outcomes. We determined internal reliability using Cronbach's alpha. One hundred two parents of children were interviewed. The average REALD-99 and REALM-66 scores were high (84 and 62, respectively). REALD-99 was positively correlated with REALM (PCC = 0.80). REALM was not related to dental outcomes. REALD-99 was associated with parents' OHIP-14 score in multivariate analysis. REALD-99 had good reliability (Cronbach's alpha = 0.86). REALD-99 has promise for measuring dental health literacy because it demonstrated good reliability and is quick and easy to administer. Additional studies are needed to examine the validity of REALD-99 using objective clinical oral health measures and more proximal outcomes such as behavior and compliance to specific health instructions.

Brief Report: screening items to identify patients with limited health literacy skills

Patients with limited literacy skills are routinely encountered in clinical practice, but they are not always identified by clinicians. To evaluate 3 candidate questions to determine their accuracy in identifying patients with limited or marginal health literacy skills. We studied 305 English-speaking adults attending a university-based primary care clinic. Demographic items, health literacy screening questions, and the Rapid Estimate of Adult Literacy in Medicine (REALM) were administered to patients. To determine the accuracy of the candidate questions for identifying limited or marginal health literacy skills, we plotted area under the receiver operating characteristic (AUROC) curves for each item, using REALM scores as a reference standard. The mean age of subjects was 49.5; 67.5% were female, 85.2% Caucasian, and 81.3% insured by TennCare and/or Medicare. Fifty-four (17.7%) had limited and 52 (17.0%) had marginal health literacy skills. One screening question, "How confident are you filling out medical forms by yourself?" was accurate in detecting limited (AUROC of 0.82; 95% confidence interval [CI]=0.77 to 0.86) and limited/marginal (AUROC of 0.79; 95% CI=0.74 to 0.83) health literacy skills. This question had significantly greater AUROC than either of the other questions (P<.01) and also a greater AUROC than questions based on demographic characteristics. One screening question may be sufficient for detecting limited and marginal health literacy skills in clinic populations.

Health Literacy in a Rural Clinic

Purpose: Health literacy is a critical prerequisite to effective self-management of any health problem. Nearly half of all adult U.S. citizens have difficulty with reading skills. For those living in rural areas who also experience health literacy deficits, self-management of health needs is doubly problematic. Rural dwellers are more likely to delay treatment for health problems and more likely to experience chronic health problems than their urban counterparts. The purpose of this research was to assess the health literacy of those seeking care in a rural health clinic. Design: The design of this descriptive study was a one-time survey using a convenience sample of 57 patients (89% Caucasian, 65% female) from a rural clinic in the southeastern United States. Data were collected in Fall 2003. Methods: The REALM (Rapid Estimate of Adult Literacy in Medicine) test and a demographic questionnaire were administered by trained nursing students to consenting patients as they arrived for clinic appointments. Data were analyzed descriptively and with non-parametric one-way ANOVA. Findings: The mean REALM score was 55.9 on a scale of 0 to 66. Half of the participants (n =29; 50.8%) read at the high school level, and 6 (11%) read at grade six or lower. Females scored significantly higher than males. The more difficult words included “impetigo,” “colitis,” “osteoporosis,” and “diagnosis.” Conclusions: Health literacy is a significant barrier to effective health care for many rural dwellers, particularly males. Health care providers can minimize the negative consequences of limited health literacy by assessing the literacy of their population and adjusting written and verbal communications accordingly.

Problems measuring prostate-related utilities in low-literacy patients

6129 Background: Measuring patient preferences for health states related to prostate cancer treatment outcomes provides valuable input to help patients make informed treatment decisions. The most accepted method for direct utility assessment is the standard reference gamble (SG). Methods: A pilot study was conducted with 21 newly diagnosed prostate cancer patients at a VA medical center. Each patient completed 6 standard gambles with health states including training exercises with mild and severe arthritis, current health, urinary incontinence, impotence, and both incontinence and impotence. They also rated each state using a visual analogue scale (VAS). The research assistant assessed patient comprehension. Responses were considered invalid if (1) they were inconsistent if combined symptoms were rated as better than either symptom alone, (2) the subject rated all scenarios at 0.5, (3) rank order of states differed from VAS, or (4) the subject rated all scenarios equal to perfect health AND the research assistant judged that there was incomprehension. Literacy was assessed in 19 of the subjects using the Rapid Estimate of Adult Literacy in Medicine (REALM). For comparative purposes, 5 urologists provided preferences for the same scenarios. Results: The mean REALM score (59) corresponded with 7th-8th grade literacy (low literacy is defined as < than 9th grade). Only 57% (12) patients gave potentially valid responses. There was a trend toward better performance in high literacy patients that did not reach statistical significance (χ2 p = 0.37). All urologists gave valid responses. Conclusions: Standard reference gamble assessments of utilities may be difficult to accurately assess in a VA population, particularly in patients with low literacy. Utilities directly elicited from low literacy patients should be done with caution, particularly when used to guide shared clinical decision-making or policy formation. No significant financial relationships to disclose.

Problems measuring prostate-related utilities in low-literacy patients

6129 Background: Measuring patient preferences for health states related to prostate cancer treatment outcomes provides valuable input to help patients make informed treatment decisions. The most accepted method for direct utility assessment is the standard reference gamble (SG). Methods: A pilot study was conducted with 21 newly diagnosed prostate cancer patients at a VA medical center. Each patient completed 6 standard gambles with health states including training exercises with mild and severe arthritis, current health, urinary incontinence, impotence, and both incontinence and impotence. They also rated each state using a visual analogue scale (VAS). The research assistant assessed patient comprehension. Responses were considered invalid if (1) they were inconsistent if combined symptoms were rated as better than either symptom alone, (2) the subject rated all scenarios at 0.5, (3) rank order of states differed from VAS, or (4) the subject rated all scenarios equal to perfect health AND the research assistant judged that there was incomprehension. Literacy was assessed in 19 of the subjects using the Rapid Estimate of Adult Literacy in Medicine (REALM). For comparative purposes, 5 urologists provided preferences for the same scenarios. Results: The mean REALM score (59) corresponded with 7th-8th grade literacy (low literacy is defined as < than 9th grade). Only 57% (12) patients gave potentially valid responses. There was a trend toward better performance in high literacy patients that did not reach statistical significance (χ2 p = 0.37). All urologists gave valid responses. Conclusions: Standard reference gamble assessments of utilities may be difficult to accurately assess in a VA population, particularly in patients with low literacy. Utilities directly elicited from low literacy patients should be done with caution, particularly when used to guide shared clinical decision-making or policy formation. No significant financial relationships to disclose.

Literacy in Primary Care Populations

Almost half of Canadians experience difficulty using print media, according to the 1994 International Adult Literacy Survey. Our objectives were to estimate the prevalence of low-literacy patients in our practice, to determine whether reading grade level is associated with self-perceived health status in primary care, and to evaluate the reading difficulty of commonly used patient education pamphlets.We surveyed a random sample of 229 patients aged 18 to 85 years presenting for scheduled and walk-in care. Main outcome measures were reading ability as estimated by word decoding skill with the validated Rapid Estimate of Adult Literacy in Medicine (REALM) and self-perceived health status using COOP/WONCA functional health measures. We assessed the reading difficulty of 120 commonly used patient education pamphlets using the Simple Measure of Gobbledygook (SMOG) formula.The prevalence of low-literate patients was 9%. Poor reading ability in English was most likely among patients under 45 years of age not having completed high school, and among those whose maternal language was neither English nor French (immigrants). REALM scores and self-perceived health were weakly correlated but not significant statistically. The mean reading grade level of pamphlets was grade 11.5 (SD: 1.5). Seventy-eight percent of pamphlets required at least a high school reading level.Literacy levels were higher than expected in our patient population; this finding may be due to the rapid assessment tool used, which may have underestimated the difficulty of using print media. Clearly, the vast majority of commonly used patient education materials would not meet the needs of low-literate patients, who may be more likely to experience poorer health. Providers need to be sensitive to the reading limitations of patients and patient education materials should be written at a lower reading level.

Literacy in primary care populations: is it a problem?

Almost half of Canadians experience difficulty using print media, according to the 1994 International Adult Literacy Survey. Our objectives were to estimate the prevalence of low-literacy patients in our practice, to determine whether reading grade level is associated with self-perceived health status in primary care, and to evaluate the reading difficulty of commonly used patient education pamphlets. We surveyed a random sample of 229 patients aged 18 to 85 years presenting for scheduled and walk-in care. Main outcome measures were reading ability as estimated by word decoding skill with the validated Rapid Estimate of Adult Literacy in Medicine (REALM) and self-perceived health status using COOP/WONCA functional health measures. We assessed the reading difficulty of 120 commonly used patient education pamphlets using the Simple Measure of Gobbledygook (SMOG) formula. The prevalence of low-literate patients was 9%. Poor reading ability in English was most likely among patients under 45 years of age not having completed high school, and among those whose maternal language was neither English nor French (immigrants). REALM scores and self-perceived health were weakly correlated but not significant statistically. The mean reading grade level of pamphlets was grade 11.5 (SD: 1.5). Seventy-eight percent of pamphlets required at least a high school reading level. Literacy levels were higher than expected in our patient population; this finding may be due to the rapid assessment tool used, which may have underestimated the difficulty of using print media. Clearly, the vast majority of commonly used patient education materials would not meet the needs of low-literate patients, who may be more likely to experience poorer health. Providers need to be sensitive to the reading limitations of patients and patient education materials should be written at a lower reading level.

Illiteracy in rheumatoid arthritis patients as determined by the Rapid Estimate of Adult Literacy in Medicine (REALM) score.

To determine the prevalence of illiteracy in a cohort of rheumatoid arthritis (RA) patients and the impact of illiteracy on disease severity and function. We performed a prospective cross-sectional study with case record review of 127 consecutive patients with RA attending one centre. All patients completed the Rapid Estimate of Adult Literacy in Medicine (REALM) screening test. This 66-word recognition test provides an estimate of reading level in less than 3 min. Demographic data were collected by interview and case record review. Function was assessed with the Health Assessment Questionnaire (HAQ) and depression with the Hospital Anxiety and Depression (HAD) scale, both sent prior to clinic attendance. Social deprivation was assessed with the Carstairs index. Four patients refused to participate. Of these, three stated they were unable to read. Ninety-seven women and 26 men agreed to be interviewed. All but two were Caucasian. Median age was 56 yr (range 19-77 yr) and median disease duration was 10 yr (range 1-60 yr). Median number of previous disease-modifying anti-rheumatic drugs (DMARDs) was two. Eighteen (15%) patients were functionally illiterate, with a REALM score of less than 60. Sex, age, disease duration and numbers of joint replacements and previous DMARDs were not influenced by illiteracy. Illiteracy led to more anxiety (P=0.011), but did not affect HAQ score (P>0.5). Illiteracy was more common in the deprived (P=0.0064). Illiterate patients had three times more hospital visits compared with age- and sex-matched RA controls over the previous 12 months. One in six of our patient population are illiterate and would struggle to cope with patient education materials and prescription labels. These patients had significantly more hospital visits but equal function, suggesting that additional resources be directed towards these individuals. The REALM test is quick and easy to administer and allows us to identify patients who may require more appropriate literature.

Relation of health literacy to gonorrhoea related care

To assess the relation between health literacy and receipt of a screening test for gonorrhoea in the past year. Study design was multisite, cross sectional survey of subjects enrolled from clinics, from community based organisations, and by street intercept. Data were obtained using face to face interview. The dependent variable was self reported receipt of a test for gonorrhoea in the past year. Health literacy was measured by the Rapid Estimate of Adult Literacy in Medicine (REALM), recoded to represent 8th grade or lower reading or 9th grade and higher reading level. Statistical analyses were adjusted to account for selection bias in literacy assessment. 54% of the sample reported at least one gonorrhoea test in the previous year. 65% of the sample read at a 9th grade level or higher. REALM score was moderately correlated with the respondent's years of education. After adjustment for missing REALM data, past suspicion of gonorrhoea, self inspection for gonorrhoea, self efficacy for care seeking, REALM score of 9th grade reading level or higher, and younger age were independently associated with gonorrhoea testing in the previous year. For the average respondent, REALM reading grade level of 9th grade or higher is associated with a 10% increase in the probability of having a gonorrhoea test in the past year. Low literacy appears to pose a barrier to care for sexually transmitted infections such as gonorrhoea.

Parental literacy level and understanding of medical information.

To ascertain the impact of literacy level on parents' understanding of medical information and ability to follow therapy prescribed for their children. A prospective cohort of parents accompanying their children for acute care. Parents were interviewed about demographic status, their child's health, and use of pediatric preventive services. The Rapid Estimate of Adult Literacy in Medicine (REALM) test was used to assess parental literacy. The same parent was interviewed 48 to 96 hours later and asked to recall the child's diagnosis, any medication prescribed, and instructions. A total of 633 patients were enrolled. Follow-up was obtained in 543 patients (85.8%). Mean parental age was 32.43 years (SD = 9.07). Mean REALM score was 57.6 (SD = 10.9), corresponding to a 7th- to 8th-grade reading level, with a mean parental educational level of 13.43 years (SD = 2.09). Low REALM score was significantly correlated with young parental age and parental education. African-American race was associated with lower REALM scores. After controlling for these variables, REALM score significantly correlated with parental perception of how sick the child was, but not with use of preventive services, comprehension of diagnosis, medication name and instructions, or ability to obtain and administer prescribed medications. Parental literacy level did not correlate with use of preventive services or parental understanding of or ability to follow medical instructions for their children.