Evaluating the Brief Health Literacy Screen

To the Editors: We commend Wallston et al. on their work, demonstrating that the Brief Health Literacy Screen (BHLS) is a useful tool in identifying hospitalized patients with low health literacy.¹ Given that about one-quarter of adults in the US have low health literacy² and that physicians often have difficulty identifying their patients’ health literacy status,³ it is imperative that clinicians have a tool that accurately identifies patients who have low health literacy.

The work of Wallston et al. demonstrating the validity of the BHLS in both the hospital and clinic setting is valuable, especially since many of the written health literacy assessment tools are difficult to use in the clinical setting. It is particularly important to have a concise and easily administered verbal screening tool, because it can easily be integrated into the clinic or hospital intake screen and does not require patients to read and respond to a written questionnaire. Since over one-third of US adults have basic or below basic literacy⁴ and we have found that more than one in four inpatients have insufficient vision,⁵ it is extremely important that we have a verbal screening tool that does not rely on patients’ vision or reading fluency.

These results are encouraging, especially since studies at our institution have found less promising results when evaluating the performance of the BHLS. In early preliminary analysis of a study we are doing comparing the verbal BHLS to both the short Test of Functional Health Literacy in Adults (S-TOFHLA) and Rapid Estimate of Adult Literacy in Medicine-Revised (REALM-R) written screening tools, we have not observed a similar correlation between the BHLS and S-TOFHLA as was found by Wallston et al.

One possibility for why our results may differ is that the patient population of our studies is very different. Wallston et al.’s study population was predominantly white, while our study’s population was predominantly African American. There was also was a higher educational attainment among participants in the Wallston study than in our study. Since Wallston et al. found that having more education and being of the white race was associated with higher health literacy scores, it is quite possible that our results are less promising because the tools may perform better in populations with high health literacy. Given these observations, it is even more important to further evaluate the utility of the BHLS in diverse patient populations, including those with low health literacy.