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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Re: Some questions about screening for literacy
Some questions about screening for literacy
Reaction and questions for discussion re: the NVS Health Literacy Assessment
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Donald W Hess MD MPH, Williamsport, PA Occupational Medicine Physician, Susquehanna Health System
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I agree that even a rapid 3 minute test would be asking a bit much on top of everything else that's expected during a routine clinical encounter in a busy practice. Since my awareness has been raised on this issue, I've been doing an instant assessment by reading the portion of the chart that has been handwritten by the patient. Coarse printing and misspellings are a tip off that the patient may have literacy issues, and I change my approach accordingly. Competing interests: None declared |
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Ian M Bennett, Philadelphia, USA Assistant Professor, University of Pennsylvania
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The NVS instrument is an exciting addition to the field of health and literacy assessment. I am interested in its design and final content. I was particularly interested in the fact that in style and appearance it is indistinguishable from items from standard adult literacy measures like the National Adult Literacy Survey (NALS, 1991), it's recent derivative the Health Activities of Literacy Survey (HALS), the Test of Adult Basic Education (TABE), and the CASAS. Nutrition labels are used just as they are here. It's too bad that a direct assessment of literacy using one of these measures wasn't used instead of the TOFHLA which is a measure often viewed as a "health literacy" instrument. The paper is appropriately titled a quick assessment of literacy rather than health literacy as we will probably never be able to screen for something as complex as the health literacy construct as defined by the IOM. Someone should now determine if we shouldn't just use a measure from the adult literacy world (and we will truly have come full circle). I was also interested in what people thought about exploring health- skill specific measures which could both assess general literacy and be useful for the needs of the particular health care setting. As an example a nutritionist might find the NVS a handy starting point for teaching about nutrition and shopping for healthy foods. It may be time to explore some other more specific measures as well which could be used to help teach and assess self-care skills. Finally, I have to once again bring up the age old question of whether it makes sense to screen patients for low literacy in the first place. If we should use the same approaches that would help patients with low literacy for all of our patients why would we want to subject specific patients to the literacy task? One thing I could see is carrying out a prevalence assessment of the number of patients with low literacy in a particular practice just to know. But that would be a limited exercise and not one used for each and every patient. I have the feeling that even at 3 minutes physicians would start picking and choosing who to give the assessment to and it is well documented that physicians are terrible at identifying who has low literacy. The whole point would be lost. Competing interests: None declared |
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Diane K. King, Denver, U.S.A. Researcher, Clinical Research Unit, Kaiser Permanente
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Addressing health literacy is critical to addressing health disparities, so I was pleased to read Weiss, et al’s (2005) article. The Newest Vital Sign (NVS) instrument provides many desirable features: brief screening of multiple dimensions of literacy (i.e., reading, numeracy, and reasoning), high sensitivity, and availability in Spanish. The instrument did, however, raise a few questions for me, thus I look forward to hearing the perspectives of others doing this work. First, the NVS overestimated the percentage of patients with limited literacy most likely due to its heavy emphasis on mental math skills. The first item, “If you eat the entire container, how many calories will you eat?” may be construed by some patients to be a “trick” question, as it does require the individual to look first for servings per container and then multiply by calories per serving. Other items required more complex math ability, including understanding how to calculate a percentage. While I don’t question the predictive value of the items, my concern is whether patients might feel embarrassed if they are unable to perform these skills in their doctor’s office. Second, when we currently use the S-TOHFLA, patients easily understand the relevance of the items (i.e., all items are healthcare related). Although it’s true that we want patients to attend more to nutrition labels, I wonder how the instrument should be positioned so that patients don’t experience dissonance between their ability to understand an ice cream label and their understanding of written medical instructions. Third, I wonder if patients who receive the NVS from multiple providers in multiple settings will “learn” the answers more easily than with other, less memorable instruments (e.g., once you catch on that “peanuts” are in the ingredient list, you likely will answer that question correctly in the future). On a related note, should healthcare providers share the results with patients? Patients may ask for the answers, and clinicians may feel that it provides a “teachable moment” with regard to understanding how to read nutrition labels. My last comment relates to the authors’ question re: “whether raising clinicians’ awareness of patients’ literacy … results in improved clinician-patient communication and better health outcomes.” While routinely assessing patient literacy is important to raising clinician awareness, I wonder if the emphasis should instead be on assessing health communication materials and reducing their literacy level, i.e., taking a more Universal Design approach to improving health communication. Competing interests: None declared |
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