Implementation of the Newest Vital Sign for assessing health literacy in clinical practice: challenges, opportunities, and future directions

INTRODUCTION

In recent years, the concept of health literacy (HL) has gained increasing recognition in both scientific literature and medical practice, emerging as a key factor in enhancing healthcare quality and preventing medical incidents. This term encompasses an individual’s knowledge, motivation, and skills in acquiring, understanding, and effectively utilizing medical information to support health improvement, maintenance, and recovery [1]. International healthcare organizations emphasize strengthening HL as a priority for the healthcare sector [2]. The World Health Organization (WHO) has identified the promotion of HL among patients as a strategic goal, which, in turn, may contribute to reducing health disparities, shortening treatment and hospitalization periods, and preventing chronic diseases. In the long run, these efforts could also lead to lower economic burdens on healthcare systems. To achieve these objectives, it is essential to incorporate effective tools into clinical practice that enable healthcare professionals to identify individuals with low HL levels. The data collected through such assessments can be utilized to develop personalized strategies for strengthening HL, as well as tailored care, treatment, and education plans [3]. A review of the literature indicated the availability of 44 different tools for assessing HL. Among the four most frequently used instruments is the Newest Vital Sign (NVS), designed for rapid HL assessment in less than five minutes. Given its potential to provide a quick yet reliable assessment of HL in clinical settings, the NVS was selected for analysis in this study. Unlike more time-consuming tools, the NVS allows for efficient screening during routine medical visits, making it a promising option in busy healthcare environments. Furthermore, its practical application aligns with current efforts to integrate HL assessment into standard patient care, ensuring timely identification of individuals who may require additional support and education [4, 5].
The purpose of the present research was to evaluate the feasibility of using the NVS tool in assessing patients’ health literacy in clinical practice based on a review of the available literature.

METHODOLOGY

A review was conducted using the PubMed database and Google Scholar to ensure a comprehensive evaluation of relevant literature. The selection criteria included peer-reviewed articles published in English that specifically addressed the use of the NVS for assessing HL in clinical practice. The review covered publications from 2005 to 2024 with additional theoretical background drawn from earlier key sources. To enhance transparency and reliability, the selection process followed structured steps similar to PRISMA guidelines, including systematic literature searching and screening. However, as this is not a full systematic review, some methodological elements, such as a meta-analysis and risk-of-bias assessment, were not included. The search strategy incorporated Medical Subject Headings (MeSH) terms, including “health literacy”, “screening tools”, and “health assessment”, as well as relevant keywords such as “Newest Vital Sign”, “health literacy assessment”, and “clinical practice”. Boolean operators (AND, OR) were applied to refine the search results and ensure a thorough selection of studies. The initial database search identified 1,189 articles. After removing 297 duplicate records, a total of 892 unique studies remained. Titles and abstracts were screened for relevance, leading to the exclusion of studies that did not meet the eligibility criteria. The full texts of potentially relevant articles were assessed, and those failing to meet inclusion criteria due to methodological limitations, lack of primary data, significant theoretical contribution or irrelevance were excluded. Ultimately, 27 empirical studies met the final inclusion criteria, focusing on the application, validation, and effectiveness of the NVS in clinical practice. Additionally, 10 sources were included to provide theoretical background on health literacy concepts, screening tools, and broader implications of HL assessment in healthcare systems. Studies were included if they explicitly examined the NVS in clinical practice, were published in peer-reviewed journals, and provided quantitative or qualitative data on HL assessment using the NVS. Additionally, theoretical sources providing significant background on health literacy concepts were included. Studies were excluded if they did not directly evaluate the NVS in patient populations, were review articles, commentaries, or opinion pieces lacking primary data or significant theoretical contribution, presented insufficient methodological details or had irrelevant outcomes or study objectives. The detailed process of study selection and exclusion is illustrated using a PRISMA flow diagram (Fig. 1).
The reviewed literature highlighted both the strengths and limitations of the NVS as a health literacy screening tool, offering a foundation for discussing its practical implementation in clinical practice. The following sections will explore key findings, challenges, opportunities, and future directions based on the extracted data.

THE NVS – A BRIEF OVERVIEW

Until 2005, the most commonly used tool for assessing HL was the TOFHLA (Test of Functional Health Literacy in Adults). The time required to assess HL using the full version of this tool ranged from 18 to 22 minutes. An alternative tool, the S-TOFHLA (Short Test of Functional Health Literacy in Adults), allows for assessment in approximately 8 minutes, which still poses a significant time challenge, limiting its effective implementation in daily medical practice [6, 7].
The increasing need for a quick and efficient HL assessment tool motivated a team of researchers from the University of Arizona College of Medicine, in collaboration with the pharmaceutical company Pfizer, to develop the NVS in 2005, using the TOFHLA as a reference standard [5]. In its original version, the NVS involves presenting the patient with a nutrition label from an ice cream container, which provides detailed information about the product. The examiner then asks six questions assessing the ability to: 1) calculate calories per serving, 2) interpret fat, sugar, and protein content, and 3) apply this information to a recommended diet. The level of HL is determined by the number of correct answers. If the patient provides 4 to 6 correct answers, their HL level is considered adequate. If 2 or 3 answers are correct, this indicates a possibility of a limited level of HL and difficulties in understanding basic health information. If the patient provides 0 or 1 correct answer, their HL level is assessed as limited literacy, indicating significant challenges in comprehending the label and its contents. The tool allows for a HL assessment in approximately three minutes. The fundamental principle is that the test should be conducted individually during a patient interview. In its original version, it is not permitted to administer the test as a survey or in a group setting [8-11]. It is recommended that the NVS be administered by a nurse or another appropriately trained healthcare team member. The assessment can be performed simultaneously with the measurement of other vital parameters, facilitating the integration of the NVS into routine care. The test result should be recorded in the patient’s medical documentation. While many other HL assessment tools exist, the NVS distinguishes itself by being significantly shorter and more practical for use in clinical settings. Unlike the TOFHLA and S-TOFHLA, which require extensive reading and numerical comprehension, the NVS utilizes a real-world context (a nutrition label), making it a functional and efficient screening tool [10, 12]. A comparison of these tools is presented in Table 1.

THE RATIONALE FOR IMPLEMENTING THE NVS IN CLINICAL PRACTICE

According to a study conducted by Osborn et al., the NVS can be effectively used in clinical settings for the rapid and accurate identification of patients experiencing health issues resulting from low HL levels. This tool enables the assessment of patients’ ability to comprehend health-related information and make informed decisions based on that knowledge. The study also suggests that the NVS can be valuable across various populations, contributing to the optimization of communication between healthcare professionals and patients [13]. The need to introduce the NVS stems from the challenges healthcare professionals face when evaluating patients’ HL. This issue is corroborated by the findings of Welch et al., who analyzed the application of the NVS in clinical practice. Their study demonstrated that using the NVS allows physicians to quickly assess patients’ HL levels and appropriately tailor treatment, prevention, and health education plans. At the same time, the researchers noted that HL assessment remains limited due to the lack of available tools. They highlighted the necessity of training programs and integrating the NVS into clinical practice to promote a holistic approach to patient care, improve communication, and reduce errors and misunderstandings in the treatment process. These measures ultimately lead to better-quality healthcare services [14]. The necessity of applying HL assessment tools is further supported by a study conducted among nurses by Dickens et al., which revealed that nurses tend to overestimate their patients’ HL levels. Such misjudgment may negatively impact the effectiveness of treatment and overall quality of care [15]. A similar issue has been observed among physicians, who often overestimate their patients’ HL levels, assuming them to be sufficient. However, NVS-based assessment has shown that 25% of patients actually exhibit limited HL. These findings underscore the importance of educational programs and the use of simplified communication strategies. They also indicate that the NVS may serve as a predictor of health risks in patients with low HL, highlighting the need for specialized care and education for this group [16]. The study by Welch et al. focused on the practical implementation of the NVS in clinical settings, evaluating the time and costs associated with its application. The researchers observed that despite the initial investments in staff training, the NVS enables faster and more precise identification of patients with limited HL. This, in turn, allows for the adjustment of healthcare services to patients’ needs, ultimately leading to improved treatment quality and a reduction in healthcare costs [14]. Assessing HL levels is also a critical aspect of providing care for elderly individuals. The lack of a systematic approach to evaluating HL among older adults creates barriers to effective communication, education, and patient motivation. Given the health and caregiving challenges faced by the elderly population, the absence of proper HL assessment may result in worsening health conditions and, consequently, an increased burden on the healthcare system [17].

APPLICATION OF THE NVS IN CLINICAL PRACTICE

The NVS was originally developed in English. Due to its ability to rapidly assess a patient’s HL, an increasing number of countries have undertaken its translation and validation, ultimately integrating the NVS into clinical practice. For example, the NVS has been successfully adapted for use in different languages, as seen in studies conducted in Taiwan, while research in the UK has primarily focused on its validation and clinical application within English-speaking healthcare environments [18, 19]. This tool has also been translated into Spanish, Portuguese, Dutch, Arabic, and other languages and is among the most widely validated HL assessment tools in countries across the Eastern Mediterranean region [20]. Subsequent studies have validated the effectiveness of the NVS across different populations and healthcare settings, reinforcing its credibility as a rapid and practical HL assessment tool. Its utility in primary care settings has been particularly emphasized, as healthcare providers increasingly recognize the importance of HL in improving patient outcomes and engagement in their own care [21]. Available literature highlights the broad application of the NVS in assessing HL levels among various patient populations with different medical conditions. For instance, research conducted in Portugal demonstrated that the NVS can effectively measure health literacy levels and identify at-risk populations within the Portuguese healthcare system [22]. The use of the NVS is particularly recommended in chronic disease management, as it allows for better patient education planning and the adaptation of educational materials to the patient’s cognitive abilities and long-term needs [23, 24]. For example, research on diabetic patients has shown that individuals with lower HL, as assessed by the NVS, often struggle with disease management, which emphasizes the need for tailored intervention strategies [25, 26]. Furthermore, even among HIV patients, studies show a strong correlation between HL levels and disease management effectiveness. Research has demonstrated that patients with low HL have higher HIV viral loads, whereas those with lower plasma viral loads exhibit adequate HL [27]. The NVS plays a crucial role in identifying vulnerable populations with low HL. It is particularly useful in elderly patients, as it assesses both numerical skills and the ability to process information. Studies indicate that lower HL levels, as measured by the NVS, correlate with cognitive decline, including memory and executive function impairments, which are essential for making informed health decisions. As emphasized in the study by Bonaccorsi et al., the NVS helps identify high-risk individuals who require specialized educational support and assistance in navigating the healthcare system, which is key to reducing health disparities [28, 29]. The NVS has also been applied in pregnant women, with studies indicating a correlation between low HL levels and low education levels, low income, and unemployment. Additionally, research suggests that carbohydrate metabolism disorders in pregnant women are linked to low HL levels, providing valuable information for healthcare professionals in planning maternal and neonatal care [30]. In a study by Chang et al., researchers highlighted the broad application of the NVS in assessing HL among surgical patients. The authors emphasized that the NVS is a key and widely used tool for identifying patients with low HL levels. In surgical patients, NVS results contribute to optimizing preoperative education, reducing communication errors, and ultimately improving the quality of care and minimizing postoperative complications [31]. A literature review conducted by Hesselink et al. analyzed various HL assessment tools used in emergency departments, including the NVS. The study highlighted the high effectiveness of the NVS in quickly and efficiently identifying patients with limited HL. Research findings indicate that the NVS also demonstrates high accuracy in assessing HL and can serve as an initial screening tool for diagnosing health-related communication issues and treatment misunderstandings. The authors of the review emphasize the significance of the NVS in clinical practice, recommending its use as a screening tool to help improve communication strategies and develop appropriate educational interventions. However, researchers also underscore the need for further studies to confirm the effectiveness of the NVS across different clinical contexts [32]. Additionally, research has explored the use of the NVS in pediatric and adolescent populations, demonstrating its reliability as an HL assessment tool for younger patients [33-35].

CHALLENGES IN IMPLEMENTING THE NVS IN CLINICAL PRACTICE

The implementation of the NVS in clinical practice requires training healthcare personnel in HL, patient communication, and the practical application of test results. Another fundamental component of this training is an understanding of how to use the results to enhance patient education and communication [14]. One of the most effective methods for improving communication skills when working with patients with low HL is the teach-back method, which should become standard practice in patient education and communication, regardless of HL levels. The teach-back method involves a healthcare provider asking the patient to repeat in their own words the information conveyed during the consultation. This approach ensures that the patient has correctly understood the message and can accurately follow medical recommendations. Additionally, it enhances patient engagement and improves health outcomes. There is a clear need to incorporate HL concepts into academic training, alongside teaching the teach-back method [16, 36]. A major challenge that hinders the development of HL in both clinical practice and research is the requirement that most assessment tools, including the NVS, be administered in person. Although the NVS test takes approximately three minutes, it may still be perceived as a barrier by both healthcare providers and patients. Canadian researchers developed a computerized version of the NVS, demonstrating that the results were equivalent to those obtained through face-to-face administration. This finding offers hope for more widespread and less time-consuming application of the tool in the future [37]. In addition, the NVS has been tested in telephone-based assessments, which may facilitate its use, particularly in research contexts [28]. Researchers emphasize the critical role of accuracy and thoughtful tool selection in the translation and validation process of HL assessment tools. An example of this challenge is the attempt to translate the NVS into Arabic, where the translated version lost its statistical validity among Arabic-speaking populations [20].

CONCLUSIONS

The integration of the NVS into routine clinical practice represents an important step toward improving healthcare quality. This tool allows for the rapid assessment of patients’ HL levels, facilitating better communication and treatment planning. However, its implementation presents challenges, including the need for staff training, time constraints, and integration with existing healthcare systems. On the other hand, the NVS offers significant advantages, such as better identification of patients requiring additional support and the ability to personalize patient care more effectively. While the adoption of the NVS requires time and commitment, its long-term benefits can greatly enhance treatment quality and patient satisfaction.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References