As patient-centered education efforts increase, assessing health literacy (HL) becomes more salient. The verbal BHLS may have clinical and feasibility advantages over written tools, including the REALM-R and S-TOFHLA, however the BHLS’ utility among inpatients remains unresolved. Hospitalized adults were enrolled; HL was assessed using three tools. Categorical comparisons used Chi-square; AUROC curve was calculated (reference: REALM-R). The prevalence of low HL among participants (n=260) was higher for the BHLS than S-TOFHLA (29% vs. 17%, p<0.001) and higher for the REALM-R than both the BHLS (44% vs. 29%, p=0.004) and S-TOFHLA (44% vs. 17%, p<0.001). The AUROCs were 0.58 for BHLS and 0.66 for S-TOFHLA. The different prevalence of low HL among the participants based on each tool likely reflects the complexity of measuring HL and differing domains captured by each tool. The BHLS can be considered a viable inpatient HL screening tool, given its increased feasibility and verbal administration.

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 literacy 2 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 literacy 4 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.

Insufficient vision is a common but under-recognized risk factor among hospitalized patients that affects patient safety and self-care. Nurses may be ideal providers to screen inpatients’ vision, but little is known regarding their knowledge of inpatient vision, screening skills, and willingness to serve as screeners. We conducted a pilot, prospective, qualitative, and quantitative interview study and enrolled 25 consenting registered nurses. Descriptive statistics were employed to analyze discrete questionnaire items and responses to qualitative open-ended items. Forty-eight percent (12/25) of nurses believed that vision problems were “moderately common,” half (13/25) did not know how to administer vision screenings, and three-quarters (19/25) had never administered screenings. Half of nurses (12/25) believed vision screening would be feasible, though over half (14/25) believed physicians should conduct the screening. This study underscores the necessity and positive support for inpatient vision screening; however, while nurses play a critical role, an inter-professional approach should be explored.