Quick Assessment of Literacy in Primary Care: The Newest Vital Sign

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