By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

What does a pint of ice cream have to do with health literacy? Quite a lot, according to Barry D. Weiss, MD, who is professor of family and community medicine at the University of Arizona College of Medicine. He and his research team, along with colleagues at the University of North Carolina, designed a nutritional label from an ice-cream container to create a literacy screening tool for health information called the Newest Vital Sign (NVS).

NVS is not the first health literacy screening tool. But while several others are highly regarded, Weiss wanted a tool that was quick to administer and could be given in multiple languages. The answer was the NVS. It takes about three minutes to administer and is available in English or Spanish, with the potential to be useful in other languages as well.

How the NVS works

For the NVS, patients are shown an ice-cream label and asked six questions:

• If you eat the entire container, how many calories will you eat?
• If you are allowed to eat 60 grams of carbohydrates as a snack, how much ice cream could you have?
• Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42g of saturated fat each day, which includes one serving of ice cream. If you stop eating ice cream, how many grams of saturated fat would you be consuming each day?
• Pretend that you are allergic to the following substances: penicillin, peanuts, latex gloves, and bee stings. Is it safe for you to eat this ice cream?
• If the patient answers “no” to the preceding question—which is the correct answer, because one of the ingredients listed on the label is peanut oil—then ask: Why not?

Patients receive one point for each correct answer. A score of 0-1 indicates a high likelihood the patient has limited literacy. A score of 2-3 indicates a possibility of limited literacy, and a score of 4-6 almost always indicates a patient has adequate literacy to navigate the healthcare system.

A learning tool for providers

Weiss likens the NVS to a mammogram, which screens for possible problems, but does not say for sure if there is one. Similarly, the NVS screens for limited literacy, but cannot give a precise measurement of an individual’s literacy skills.

As a practicing physician, Weiss feels the NVS is best used to size up the health-literacy skills of a patient population, rather than to assess the skills of specific individuals. Giving it to 200 consecutive patients is often “eye-opening and awareness-raising,” says Weiss. When providers tally their patients’ scores, they often are astounded at the extent of literacy problems the test reveals. Weiss says this data helps motivate clinicians to “clean up their act” and learn to communicate in more effective ways, more of the time

Weiss does not advocate routinely testing all patients. This is partly a matter of practicality due to timing and other logistics, and partly because few providers can (or will) adjust their communication style specific to each patient. As well, Weiss does not feel that the NVS is suitable for hospitalized patients, who are often too sick to participate. That said, one situation in which he does see the benefit of routine screening is when counseling patients at discharge about nutrition and diet.

Frequently asked questions

Weiss says many providers have questions and concerns about using the NVS. During our recent conversation, he provided me with a list of the most common questions and the answers he usually gives:

• Can I use the NVS in a written form? The NVS is only validated for oral administration, says Weiss. It was designed this way because of the need for patients to interpret and understand what their providers say.
• Who should administer the NVS? Often, the NVS is given by the person who “rooms” each new patient. It can be done along with taking the patient’s vital signs.
• How long does it take? Studies show that the NVS can be given in an average of three minutes. While some patients are stymied no matter how long they take, Weiss recommends stopping when patients struggle to get only 0-2 correct answers.
• Can I ask just one question, not all six? Weiss’s preliminary research shows that if a patient gets the two-part question about peanut allergy correct or incorrect, it pretty much predicts scores for all six questions. But, he says, “the jury is still out” about whether asking just these two questions always works as well as administering the whole test. For now, he recommends asking all six questions because they provide insight about a range of health-literacy skills.
• Should results be documented? Practices that routinely screen all patients often record scores in the medical record alongside vital signs. Weiss cautions that the NVS does not give “perfect specificity.” For instance, the implications are unknown if a patient scores two correct responses as opposed to three.
• Is there any cost or is permission needed? Weiss says that clinicians are free to use the NVS. There is no fee or need for permission. You can download copies of this instrument along with other information by going to the Pfizer Clear Health Communication Web site.

Weiss and his colleagues not only researched how well the NVS works for providers, they also asked patients. They gave the NVS to patients in 20 medical practices located in urban community health centers, suburban “upscale” practices, and remote rural clinics. In this randomized study, virtually all patients reported that they found this test acceptable, and that completing it made no difference in their level of satisfaction.

This finding counters the argument that patients, especially “new readers” (adults learning to read) are upset, embarrassed, or ashamed when given this type of test. To Weiss, this is likely because the NVS is not a reading test, per se. Instead, most people perceive a nutritional label as an important health tool.

Weiss hears many stories about the benefits of the NVS. He mentions how his research assistant used the NVS to screen new mothers for post-partum depression. The assistant was flabbergasted to see that few women could correctly answer more than a question or two. She hadn’t before fully appreciated the scope of the problem, in which printed materials often fail to help new parents learn about caring for their babies. Thanks to the NVS, she now does.

Ways to learn more:

Barry D. Weiss, MD, is professor of family and community medicine at the University of Arizona College of Medicine. Email him at bdweiss@email.arizona.edu.

Weiss BD, et al. “Quick Assessment of Literacy in Primary Care: The Newest Vital Sign,” Annals of Family Medicine: Vol. 3, No. 6, November/December 2005.

Ryan JG, et al. “Will patients agree to have their literacy skills assessed in clinical practice?” Health Education Research, September 22, 2007.

Helen Osborne, MEd, OTR/L, is president of Health Literacy Consulting. Her column appeared regularly in On Call. You can contact her by e-mail at Helen@healthliteracy.com.