Health Literacy - The "Newest Vital Sign"?

In the very beginning of the summer, I met with the medical director of PSI to gain her input on my project. I outlined my ideas for the Health Literacy curriculum, and she added that she would like me to include a lesson on the "Newest Vital Sign". It consists of a Nutrition Facts label followed by six questions relating to the label. It is meant to be used by physicians as a screening tool for their patients' health literacy levels, completed at each patient's first visit. It is called the newest vital sign since heath literacy levels may be just as important to health care decisions as a patient's heart rate and blood pressure.

The Newest Vital Sign test was developed because of the lack of rapid and valid health literacy assessments physicians can use with their patients. Older tests include the TOFHLA (Test Of Functional Health Literacy in Adults) and the REALM (Rapid Estimate of Adult Literacy in Medicine). The TOFHLA consists of reading a passage and answering questions about it, which is too time-consuming for most clinical settings. The REALM consists of simply reading a list of medical terms aloud, but being able to pronounce words doesn't necessarily imply comprehension. In contrast to older tests, the Newest Vital Sign assessment only takes about 3 minutes, and asks patients to interpret health information, not simply read it. For these reasons, I do think that the Newest Vital Sign test is an improvement on the previously developed tests. The questions include:

The label used in the 
Newest Vital Sign Assessment.

1. If you eat the entire container, how many calories will you eat?

2. If you are allowed to eat 60 grams of carbohydrates as a snack, how many servings of ice cream could you have?

3. Your doctor advises you to reduce the amount of saturated fat in your diet. You usually have 42 g 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?

4. If you usually eat 2500 calories in a day, what percentage of your daily value of calories will you be eating if you eat one serving?

5. 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?

6. Why or why not?

A score of 0-1 indicates a high likelihood of limited health literacy; 2-3 indicates a possibility of limited health literacy; 4-6 almost always indicates adequate literacy. Although it is more practical than the TOFHLA and more valid than the REALM, I'm still not convinced that the Newest Vital Sign assessment is a great predictor of health literacy levels. First of all, the first four questions all test the same basic math skills. If a patient can't do mental math, they would automatically receive a score of a 2 or less. Additionally, getting #6 right depends on having answered #5 right. And perhaps most importantly, does the ability to understand a Nutrition Facts label necessarily reflect the ability to comprehend all health-related information? The literature shows a mixed response to this question, with some studies showing that it is a valid assessment, with others arguing that it may miss the mark.

I apologize for the digression; after all, I wasn't using the Newest Vital Sign as a test of my students' health literacy levels. Rather, the medical director asked me to use the activity to teach the patients about nutrition. When I was first presented with this idea, I felt overwhelmed because of the difficulty of the questions asked on the test, combined with the patient's low literacy and numeracy skills. I met with both the GED teacher and the nutritionist here to get their opinions on how I could most effectively teach the math skills needed to complete this assessment. I ended up giving the lesson last week, and it went great. First we practiced doing similar types of calculations from Nutrition Facts labels, and then I gave them the Newest Vital Sign test at the end of class. They earned an average of 82%, which is considered true mastery from a teacher's perspective (and adequate literacy from the test writer's perspective). The patients here are so hungry for knowledge and work so hard for me. It seems like whatever work I give them, they continue to exceed my expectations.