The Rapid Estimate of Adult Literacy in Genetics (REAL-G): A means to assess literacy deficits in the context of genetics

Genetic information presents challenges to all patients, but particularly those with low and marginal literacy. The goal of the study was to create a rapid estimate of adult literacy in genetics (REAL-G) tool, with established validity, for use with patients receiving genetics services. Patterned after the widely used rapid estimate of adult literacy in medicine (REALM), a three-stage method was used in tool development. This included derivation of terms from transcripts of visits conducted by over 150 prenatal and cancer genetic counselors. Concurrent validity was estimated by administration of both the REAL-G and the REALM to 203 participants. Predictive validity was estimated by relating participants' REAL-G scores to scores on a learning task that involved viewing a videotaped genetic counseling session and answering related questions. The REAL-G measure was strongly correlated with the REALM (Pearson correlation = 0.83; P < 0.0001), indicating substantial concurrent validity in a population of potential genetic counseling patients. Using the REALM as the gold standard, REAL-G scores identified readers at the sixth grade level or below (95.4% sensitivity and 88.5% specificity). Further analysis identified an eight-item subset of words that has strong concurrent validity when compared to longer instruments and even greater predictive power in relation to information recall. Subjects scoring below the sixth grade level on the eight-item REAL-G scored significantly lower than others on knowledge tests after viewing genetic counseling visits. The REAL-G represents a screening tool that can be used to quickly identify low literate patients in the clinical genetics context or to quantify context-specific literacy within a research setting.