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Neighborhood Vulnerability Index Identifies Spine Clinic Patients With Limited Health Literacy

Key findings

  • This cross-sectional study investigated factors associated with health literacy in patients attending an outpatient spine clinic
  • The prevalence of limited health literacy among study participants was 33% (135 of 405 patients)
  • One of the factors associated with limited health literacy was a higher state decile on the Area Deprivation Index (β, 0.10; P=0.038), which can be determined using online mapping tools and individual patient addresses
  • Neighborhood social vulnerability measures may be a feasible way for busy spine clinics to identify patients likely to have limited health literacy

Multiple studies have demonstrated that patients with limited health literacy are more likely to have worse self-reported health, more hospitalizations, longer hospitalizations after surgical procedures, more emergency room visits, and higher mortality than individuals with adequate health literacy.

A cross-sectional study in an outpatient spine center at Massachusetts General Hospital revealed that a substantial portion of patients had limited health literacy, and the risk was greater among socially disadvantaged patients.

Amanda Lans, MD, MS, a spine research fellow in the Mass General Department of Orthopaedic Surgery, Joseph H. Schwab, MD, MS, chief of the Orthopaedic Spine Service and director of spine oncology, and colleagues report the details in The Spine Journal.


405 adults agreed to participate in the study between December 2021 and March 2022. All were new to the clinic and fluent in English. Participants were asked to complete the following verbally:

  • A sociodemographic survey
  • The Newest Vital Sign (NVS) health literacy test, in which a research assistant asks six questions about an ice cream nutrition label, and the patient receives one point for each correct answer; 4−6 points indicate adequate health literacy, and 0−3 points indicate limited health literacy
  • The Rapid Assessment of Adult Literacy in Medicine Short Form (REALM-SF), in which patients are asked to read seven words out loud; scores were categorized as below ninth-grade reading level (<7 correct words) and at least ninth-grade reading level (7 correct words)

In addition, the research team extracted the Social Vulnerability Index (SVI) and Area Deprivation Index (ADI) using online mapping tools and individual patient addresses:

  • The SVI consists of separate scores for socioeconomic status, household composition and disability, minority status and language, and housing and transportation
  • The ADI consists of 17 census variables reflecting socioeconomic status based on income, education, household characteristics, and housing; scores are presented in state deciles and national percentiles, where higher scores indicate greater deprivation


135 patients (33%) were found to have limited health literacy. On multivariable regression analysis, limited health literacy was independently associated with the following:

  • Higher ADI state decile (β, 0.10; P=0.038)
  • Living less than 10 years at current address (β, −0.79; P=0.021)
  • Having housing insecurity (β, −1.05; P=0.045)
  • Not being employed (β, 0.81; P=0.028)
  • Not being a native speaker of English (β, 1.00; P=0.038)
  • Having fewer years of education (β, 1.74; P<0.001)
  • Having less than a ninth-grade reading level (β, 1.03; P=0.017)

Applying the Results to Practice

Once a patient is known to have limited health literacy, clinicians may offer additional resources or different methods of instruction, even before the patient's visit. Furthermore, clinicians may choose to spend more time in shared decision-making interactions.

However, assessing health literacy in busy clinics is challenging. The NVS is accurate, but its length and method of administration make it impractical to add to the routine workflow.

This study suggests ADI state decile could be a reliable indicator of limited health literacy in patients with spine-related complaints. The ADI can be determined from a patient's address, obviating the need to assess health literacy with other tools. Future studies should assess whether ADI is associated with health literacy in other orthopedic patient populations.

of new patients at an outpatient spine clinic had limited health literacy

Learn more about the Orthopedic Spine Service at Mass General

Learn more about the Spine Surgery Fellowship at Mass General

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