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Reading and Rheumatoid Arthritis


Many of us will have seen British television advertisements for people with low reading or numeracy skills. Most of us immediately forget them. A survey of illiteracy in rheumatoid arthritis patients in Glasgow [1] suggests that we need to pay the subject more attention.


A tertiary referral centre for rheumatic diseases invited attendees of four consecutive clinics for rheumatoid arthritis patients to participate. All gave verbal consent for participation after a prepared consent form had been read to them (important this).

Patients were asked to complete the REALM questionnaire. This is the Rapid Estimate of Adult Literacy in Medicine [2], a screening instrument of 66 routinely-used lay medical terms arranged in three columns of increasing difficulty and number of syllables, ranging from 'fat' and 'flu' to 'jaundice', 'medication' and 'inflammatory'. A patient is asked to read the words aloud, scoring one point for every word read correctly and zero if the word is mispronounced or not attempted. The maximum possible score is 66 and scores can be translated into reading ages of school grades (Table 1).

Table 1: REALM scores, reading age equivalents in the UK and USA, and results from 126 rheumatoid arthritis patients in Glasgow

Raw score


RA patients

No test, said could not read 3/126
0-18 UK reading age 8-9 years (US third grade and below)
Will not be able to read most low-literacy materials and needs repeated oral instructions
19-44 UK reading age 9-12 years (US fourth to sixth grade)
Will need low-literacy materials and may not be able to read prescription labels
45-60 UK reading age 12-13 years (US seventh and eighth grade)
Will struggle with most patient education materials; not offended by low-literacy materials
61-66 UK reading age 16 years (US high school)
Will be able to read most patient education materials

Other information on patients was obtained at the interview and from medical records.


Of 127 patients asked to take part, four declined. Three said they were unable to read. The remaining 123 were aged 19 to 77 years, and had had rheumatoid arthritis for 1-60 years. Most (97) were women. Eighteen of the 123 had a REALM score of 60 or below, indicating functional illiteracy (Table 1). Together with the three patients who could not read, 21/126 patients (17%, or 1 in 6) would at best struggle with patient education material and 1 in 20 could not read prescription labels.

Comparing the literate with the illiterate group, there was no difference in age, disease duration or number of disease modifying drugs prescribed. Illiterate patients were more likely to be socially deprived, be anxious or depressed, and be unemployed. Illiterate patients had three times more outpatient visits and visited twice as many hospital departments.


This is important stuff. If patients don't understand their medicines, that's bad, and more time and effort is going to be needed to address comprehension in patients with inadequate literacy skills. When even the most competent of us have problems with taking it all in, how much worse is it to be cut off from the written word?

Time and effort may be worth it just for efficiency. If time and effort reduced the increased rate of outpatient attendance associated with illiteracy to that for literate patients, then just under 7,000 visits might be avoided in Glasgow alone, just for patients with rheumatoid arthritis.

This paper is worth a read. There's a good review of issues around literacy and patients, and it tell us that they could find no other UK surveys in rheumatoid arthritis or other chronic diseases. Given the high rate of adverse drug reactions in the population ( Bandolier 101 ), and the emerging evidence of the problems of illiteracy on health care use, this is a prime topic to learn more about. As with so many problems, though, it's not tackled because no-one has bothered to look for it. Three cheers for Glasgow for pointing out this important point. Young professionals everywhere should see this topic as one for immediate research.


  1. MM Gordon et al. Illiteracy in rheumatoid arthritis patients as determined buy the rapid estimate of adult literacy in medicine (REALM) score. Rheumatology 2002 41: 750-754.
  2. TC Davis et al. Rapid Estimate of Adult Literacy in Medicine: a shortened screening instrument. Family Medicine 1993 25: 391-395.
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