Letters to the Editor

Assessing Patients' Health Literacy Skills Not Necessary in Clinical Practice


Am Fam Physician. 2018 Jun 15;97(12):768.

Original Article: Health Literacy Tools in the Outpatient Setting (FPIN's Help Desk Answers)

Issue Date: August 15, 2017

Available online at: https://www.aafp.org/afp/2017/0815/p252.html

To The Editor: As lead investigator of the team that developed the Newest Vital Sign1—one of the most widely used health literacy assessments2 that is available in multiple languages, is used around the world, and was found in a recent systematic review to be the most practical health literacy assessment for use in clinical practice3—I feel compelled to comment on this article. The authors discuss which health literacy tool is best for identifying patients with limited health literacy in the outpatient setting.

The correct answer to that question is that no health literacy tool should be used for this purpose. Health literacy assessment instruments—including the Newest Vital Sign, the three assessments mentioned in the FPIN's Help Desk Answers article, and other instruments not mentioned in the article—are best used for clinical and epidemiologic research. They should not be used in routine clinical practice to label patients as having adequate or inadequate health literacy skills.

Health literacy experts have long recommended against performing routine health literacy assessments in clinical settings (except for research purposes).4 Instead, the approach recommended by multiple professional organizations and in a 2015 AFP article5 is to use universal health literacy precautions6 by explaining medical information in easy-to-understand terms to all patients, regardless of their literacy skills or education level. Other than for a research project, the only reason to assess patients' health literacy skills would be if you do not believe limited health literacy is prevalent in your practice; assessing the next 100 patients who walk through the door would show how common it is.

There is no evidence that assessing patients' health literacy skills makes any difference in their clinical outcomes or health status. What does make a difference is giving patients information they can understand and act on. The Agency for Healthcare Research and Quality has produced a health literacy toolkit that provides guidance on how to achieve that goal.6 Rather than assessing patients' health literacy skills, clinicians should use the toolkit to assess their own personal communication skills and the way their practice communicates with patients, and to develop ways to improve how they and their practice provide information to patients.

Author disclosure: No relevant financial affiliations.


show all references

1. Weiss BD, Mays MZ, Martz W, et al. Quick assessment of literacy in primary care: the Newest Vital Sign [published correction appears in Ann Fam Med. 2006;4(1):83]. Ann Fam Med. 2005;3(6):514–522....

2. Shealy KM, Threatt TB. Utilization of the Newest Vital Sign (NVS) in practice in the United States. Health Comm. 2016;31(6):679–687.

3. Duell P, Wright D, Renzaho AM, Bhattacharya D. Optimal health literacy measurement for the clinical setting: a systematic review. Patient Educ Couns. 2015;98(11):1295–1307.

4. Paasche-Orlow MK, Wolf MS. Evidence does not support clinical screening of literacy. J Gen Intern Med. 2008;23(1):100–102.

5. Hersh L, Salzman B, Snyderman D. Health literacy in primary care practice. Am Fam Physician. 2015;92(2):118–124.

6. Brega AG, Barnard J, Mabachi NM, et al.; Agency for Healthcare Research and Quality. AHRQ Health Literacy Universal Precautions Toolkit. 2nd ed. https://www.ahrq.gov/sites/default/files/publications/files/healthlittoolkit2_3.pdf. Accessed December 6, 2017.

In Reply: We thank Dr. Weiss for his comments on health literacy screening and agree that there is no evidence for routine health literacy assessments in the clinical setting. Although various tools, such as the ones described, have been used in research to identify patients with poor health literacy, they have not yet been shown to improve health outcomes. Until screening has been shown to be effective, all health information should be given to all patients in formats they can understand.

Author disclosure: No relevant financial affiliations.

Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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