Comprehension Items Research Articles

Effects of Strength of Accent on an L2 Interactive Lecture Listening Comprehension Test

This article reports on a study which aimed to determine the effect of strength of accent on listening comprehension of interactive lectures. Test takers (N = 21,726) listened to an interactive lecture given by one of nine speakers and responded to six comprehension items. The test taker responses were analyzed with the Rasch computer program WINSTEPS to investigate the relative difficulty of the items associated with the nine versions of the interactive lectures. Results indicated that comprehension of interactive lectures was diminished with quite light accents, as has been found with monologic lectures.

Cognitive Interviews with Parents to Validate a Questionnaire Assessing the Quality of Home Food Supplies

Foods available at home can affect health outcomes. Time‐efficient, reliable, valid tools that accurately estimate the calorie and nutrient quality of the home food supply are needed. Thus, a 36‐item food frequency questionnaire for individual intake was modified to assess household food supply fruit and vegetable servings, calories, percent calories from fat, and nutrients (i.e., total fat, saturated fat, cholesterol, vitamin C, fiber, potassium, magnesium, sugar from sweetened beverages). As part of validation, cognitive interviews were conducted with 15 parents to assess comprehension of questionnaire items and accuracy of interpretation by having parents read each questionnaire item aloud and verbally explain what the item was asking, then select their answer to the item and state the reasoning for the answer. The instructions for completing the questionnaire were reviewed with each parent before the cognitive interview began. After the first 5 interviews, the instrument layout was revised to put fewer items on each page (similar items, such as fruits and vegetables, were grouped together on a page) and repeating questionnaire instructions at the top of each page as a reminder of how to answer the items. Overall, parents correctly interpreted questionnaire items, felt that they were quick and easy to complete, and had only minor suggestions for improvement. A few parents thought some items were redundant, mainly because parents did not differentiate between food descriptors/qualifiers (e.g., low fat vs whole milk) indicating a need for stronger visual cues in the questionnaire to facilitate differentiation (e.g., color, bold, and/or underline descriptors). Several were unsure as to whether takeout food, specifically pizza, should be counted as part of the household food supply. A few wanted to report on additional food items beyond those in the questionnaire, such as ethnic foods. Some had minor difficulties remembering the questionnaire was about household food availability not dietary intake of individual family members. Cognitive interview results indicate that a food frequency questionnaire modified for assessing household food supply is a quick, easy tool for estimating food availability in the home and is understandable and acceptable to study participants. Future research should investigate the validity of the questionnaire by comparing parent responses to actual household food supplies.Support or Funding InformationUSDA NIFA #2011‐68001‐30170

Validity and reliability of a modified english version of the physical activity questionnaire for adolescents.

BackgroundAdaptation of physical activity self-report questionnaires is sometimes required to reflect the activity behaviours of diverse populations. The processes used to modify self-report questionnaires though are typically underreported. This two-phased study used a formative approach to investigate the validity and reliability of the Physical Activity Questionnaire for Adolescents (PAQ-A) in English youth. Phase one examined test content and response process validity and subsequently informed a modified version of the PAQ-A. Phase two assessed the validity and reliability of the modified PAQ-A.MethodsIn phase one, focus groups (n = 5) were conducted with adolescents (n = 20) to investigate test content and response processes of the original PAQ-A. Based on evidence gathered in phase one, a modified version of the questionnaire was administered to participants (n = 169, 14.5 ± 1.7 years) in phase two. Internal consistency and test-retest reliability were assessed using Cronbach’s alpha and intra-class correlations, respectively. Spearman correlations were used to assess associations between modified PAQ-A scores and accelerometer-derived physical activity, self-reported fitness and physical activity self-efficacy.ResultsPhase one revealed that the original PAQ-A was unrepresentative for English youth and that item comprehension varied. Contextual and population/cultural-specific modifications were made to the PAQ-A for use in the subsequent phase. In phase two, modified PAQ-A scores had acceptable internal consistency (α = 0.72) and test-retest reliability (ICC = 0.78). Modified PAQ-A scores were significantly associated with objectively assessed moderate-to-vigorous physical activity (r = 0.39), total physical activity (r = 0.42), self-reported fitness (r = 0.35), and physical activity self-efficacy (r = 0.32) (p ≤ 0.01).ConclusionsThe modified PAQ-A had acceptable internal consistency and test-retest reliability. Modified PAQ-A scores displayed weak-to-moderate correlations with objectively measured physical activity, self-reported fitness, and self-efficacy providing evidence of satisfactory criterion and construct validity, respectively. Further testing with more diverse English samples is recommended to provide a more complete assessment of the tool.Electronic supplementary materialThe online version of this article (doi:10.1186/s13690-016-0115-2) contains supplementary material, which is available to authorized users.

Development and psychometric properties of a self-regulation scale about leisure time physical activity in Iranian male adolescents.

Background:Self-regulation is one of the current psychological concepts that have been known as a determinant of leisure time physical activity. Due to cultural and social diversity in different societies and age groups, application of specific questionnaires is essential to perform investigations about physical activities. The aim of this study is development and evaluation of psychometric properties of a self-regulation questionnaire about leisure time physical activity in Iranian male adolescents.Materials and Methods:This cross-sectional study was conducted in 2013, and data of 603 male students from 12 high schools in Isfahan were collected. A comprehensive literature review and similar questionnaire review were conducted and 25 items were selected or developed to measure self-regulation. Comprehensibility of items was evaluated in a pilot study and an expert panel evaluated face and content validity. Exploratory factors analysis (EFA) was used for evaluation of construct validity and extraction of sub-constructs of self-regulation. Leisure time physical activity was assessed using International Physical Activity Questionnaire (IPAQ).Results:The mean age of the participants was 16.3 years (SD =1.0) and the range was 15-19 years. Cronbach's α coefficient of the questionnaire in the pilot and main study was 0.84 and 0.90, respectively. EFA resulted in four sub-constructs including “enlistment of social support”, “goal setting”, “self-construction”, and “self-monitoring”, which explained 63.6% of the variance of self-regulation.Conclusions:Results of this investigation provide some support to the validity and reliability of the 16-item questionnaire of self-regulation abut leisure time physical activity in the target group.

Use of Cognitive Interviews to Adapt PROMIS Measurement Items for Spanish Speakers Living with HIV.

Purpose. To use cognitive interviewing techniques to assess comprehension of existing Patient-Reported Outcomes Measurement Information System (PROMIS) items among Latinos living with HIV and then refine items based on participant feedback. Methods. Latino monolingual Spanish speakers living with HIV (n = 56) participated in cognitive interviews. Items from four PROMIS domains, including depression, anxiety, fatigue, and alcohol use, were assessed for comprehension. Audiotaped interviews and handwritten notes were subjected to content analysis to identify problems specific to each instrument for each domain. Results. The assessments from the cognitive interviews identified areas for improvement in each domain. We present data on the type of items that were difficult to comprehend and provide examples for how items were refined based on participants' and PROMIS Statistical Coordinating Center (PSCC) feedback. Six out of 48 depression items, 7 out of the 61 anxiety items, 18 out of 42 fatigue items, and 7 out of 44 alcohol use items were found to have poor comprehension. These items were refined based on participant feedback; the items were then submitted to the PSCC for additional guidance on linguistics and grammar to improve comprehension. Conclusions. Cognitive interviews may be used to enhance comprehension of PROMIS items among Latinos.

Exploring the Role of Phraseological Knowledge in Foreign Language Reading

Foreign language (FL) knowledge has been shown to contribute significantly to FL reading performance. Studies have contrasted the contribution of FL vocabulary and syntactic knowledge, following a dichotomous view of these components, producing mixed results. Despite the increasingly recognized formulaic nature of language, the contribution made by phraseological knowledge to reading ability has not been investigated systematically. This study examines the impact of a broader construct definition of linguistic knowledge—which includes a phraseological component—in explaining variance in reading performances. Test scores of 418 learners of English as a foreign language (EFL) were modeled in a structural equation model, showing that a phraseological knowledge measure outperformed traditional syntactic and vocabulary measures in predicting reading comprehension variance. Additional insights into the role of phraseological knowledge were gained through verbal protocol analysis of 15 EFL learners answering reading comprehension items that targeted the understanding of phrasal expressions within written context. The findings hint at an underestimated, but critical, role of phraseological knowledge in FL reading, and are relevant to both the assessment and the teaching of EFL ability.

Introducing an instrument to measure body and fitness-related self-conscious emotions: The BSE-FIT

ObjectivesThe aim of this study was to develop a new self-report instrument to assess experiences of shame, guilt, authentic pride, and hubristic pride in a fitness context. Design and methodIn Study 1, 41 potential items were developed and assessed for item quality and comprehension. In Study 2, a panel of experts (N = 8; M = 10.55, SD = 6.49 years of experience) assessed the scale and items for validity evidence based on content. Participants in Study 3 (N = 435) completed the Body-related Self-Conscious Emotions Fitness instrument (BSE-FIT) and other established self-report measures of body image, personality, emotion, and behavior. A subset of participants (n = 38; 38% male) in Study 3 completed a 2-week follow-up. ResultsThe BSE-FIT subscale scores demonstrated evidence for internal consistency, temporal stability over a 2-week period, concurrent, convergent, and discriminant validity. A 4-factor conceptualization of the instrument was supported. ConclusionsOverall, the final 16-item BSE-FIT instrument shows promise as a new instrument for assessing shame, guilt, and authentic and hubristic facets of pride in fitness contexts.

Language Ability and Motivation Among Foreigners in Survey Responding

With increasing migration and linguistic diversification in many countries, survey researchers and methodologists should consider whether data provided by individuals with variable levels of command of the survey language are of the same quality. This paper examines the question of whether answers from resident foreign respondents who do not master available survey languages may suffer from problems of comprehension of survey items, especially items that are more complicated in terms of content and/or form. In addition, it addresses the extent to which motivation may affect the response quality of resident foreigners. We analyzed data from two large-scale surveys conducted in Switzerland, a country with three national languages and a burgeoning foreign population, employing a set of dependent measures of response quality, including don't know responses, extreme responding, mid-5 responding, recency effects, and straight-lining. Results show overall poorer response quality among foreigners, and indicate that both reduced language mastery and motivation among foreigners are relevant factors. This is especially true for foreign groups from countries that do not share a common language with those spoken in Switzerland. A general conclusion is that the more distant respondents are culturally and linguistically from the majority mainstream within a country, the more their data may be negatively affected. We found that more complex types of questions do generally lead to poorer response quality, but to a much lesser extent than respondent characteristics, such as nationality, command of the survey language, level of education, and age.

The Issue of Fuzzy Concepts in Test Construction and Possible Remedies

With the first issue of 2015, I want to continue the series ofeditorials aimed at highlighting specific topics relevant dur-ing test construction. More importantly, I focus on issuesthat repeatedly lead to paper rejections. In this issue, I wantto take up the cudgels for a mixed methods approach in testconstruction. The quantitative aspects of testing a newlyconstructed assessment tool range prominently within thisjournal (Alonso-Arbiol & van de Vijver, 2010). However,some issues arising during the test development processcannot be dealt with using quantitative methods alone.Along with the coauthors of this editorial – experts in theapplication of a mixed methods approach in test construc-tion – I want to explore these issues.Many test constructions show a lack of awareness con-cerning the comprehensibility of items, specifically in per-sonality tests. However, this lack of awareness can haveimplications for psychometric quality. Frequently, it is sim-ply assumed that respondents’ understanding of a test itemmatches the meaning implied by the test developer. It is,however, rarely ever tested whether all respondents of thetargeted population actually understand the test items cor-rectly and in a similar way. As pointed out in the last edito-rial (Ziegler, 2014), item content should be precisely tunedto the needs of every potential respondent in a populationtargeted by a newly developed test. More specifically, per-son variables such as age, gender, and education (Ramm-stedt & Kemper, 2011) have to be taken into accountwhen constructing test items in order to assure that eachpotential respondent fully understands the meaning andmay respond accordingly. If these person variables areneglected in the process of test construction, the psycho-metric quality of a test may be substantially affected byfuzzy concepts. The goal of this editorial is to raise aware-ness for the detrimental effects fuzzy concepts can have intest development and possible remedies.

Unknown Vocabulary Items and Reading Comprehension Tests: Comparing With-assistance and Without-assistance Performance of Iranian Students

One common concern of Iranian students in taking final English exams is the existence of several unknown vocabulary items in reading comprehension section. Students often argue that not knowing the meanings of such items negatively affects their performance. The purpose of this study was to see if providing test takers with L1 equivalents of the unknown vocabulary items would affect/enhance their reading comprehension level. Two passages were selected, each containing six multiple-choice items. Following Day and Park’s (2005) categorization, the first two items aimed at literal, the second two involved reinterpretation, and the last two were inferencing type of comprehension items. Forty nine students took the test twice. The first time they answered the questions without asking for the meaning of the unknown word. During the second administration, they were allowed to ask for the meanings of the unknown vocabulary items. Statistical analyses of data showed that ‘telling’ L1 equivalents of the unknown items led to a statistically significant difference. Further analyses, however, revealed that teacher assistance had significant effects on students’ performance on inference questions but not on their performance on literal and reinterpretation items. The potential reasons for the findings are discussed first. The findings, then, are used to argue that the commonly-held view by the students is only partially valid.

Consumer trust and distrust: retaining paper bills in online banking

Purpose– The purpose of this paper is to explore the role of paper bills and statements in online and mobile banking and how they may serve to support trust along with mitigating distrust for consumers when dealing with banks and billing firms.Design/methodology/approach– A two-phase study with 208 Canadian online bill payers. Phase 1 verified the comprehension of the measurement items being tested. In Phase 2, exploratory factor analysis was used to determine the factor structure. Regression analysis was used to identify the relationship of the factors with the intention to continuing receiving paper bills.Findings– Four factors for trust and distrust were identified in this study of which two (structural assurance and counted on to help) plus subjective norm predict the intention to continue receiving paper bills.Research limitations/implications– Trust and distrust are shown to co-exist in this study. Consumers feel vulnerable to the risks inherent in online financial interactions, but signal their willingness to trust by adopting online and mobile banking. Consumers mitigate the distrust they have in banks and billing firms by continuing to receive paper bills and statements. This study is limited to paper bills and statements. The role of other paper documents in customer relationship management is worthy of further exploration.Practical implications– This research investigates the role of financial documents in the consumer-firm relationship. This study suggests that paper bills are a communication method that supports consumers’ trust in the banks and billing firms and their adoption of online and mobile banking. Banks and billing firms’ continued emphasis on consumers’ giving up paper bills while insisting on original paper documentation in problem resolution situations, sends mixed messages to consumers, which heightens their distrust in these firms.Originality/value– This is the first study to suggest that paper bills and statements have a role in influencing trust or distrust of banks and billing firms.

Self-care Barriers Reported by Emergency Department Patients With Acute Heart Failure: A Sociotechnical Systems-Based Approach

We pilot tested a sociotechnical systems-based instrument that assesses the prevalence and nature of self-care barriers among patients presenting to the emergency department (ED) with acute heart failure. A semistructured instrument for measuring self-reported self-care barriers was developed and administered by ED clinicians and nonclinician researchers to 31 ED patients receiving a diagnosis of acute heart failure. Responses were analyzed with descriptive statistics and qualitative content analysis. Feasibility was assessed by examining participant cooperation rates, instrument completion times, item nonresponse, and data yield. Of 47 distinct self-care barriers assessed, a median of 15 per patient were indicated as "sometimes" or "often" present. Thirty-four specific barriers were reported by more than 25% of patients and 9 were reported by more than 50%. The sources of barriers included the person, self-care tasks, tools and technologies, and organizational, social, and physical contexts. Seven of the top 10 most prevalent barriers were related to patient characteristics; thenext 3, to the organizational context (eg, life disruptions). A preliminary feasibility assessment found few item nonresponses or comprehension difficulties, good cooperation, and high data yield from both closed- and open-ended items, but also found opportunities to reduce median administration time and variability. An instrument assessing self-care barriers from multiple system sources can be feasibly implemented in the ED. Further research is required to modify the instrument for widespread use and evaluate its implementation across institutions and cultural contexts. Self-care barriers measurement can be one component of broader inquiry into the distributed health-related "work" activity of patients, caregivers, and clinicians.

Psychometric Properties of Science Items Comprehension Test

This study aimed to develop Science Items Comprehension Test (SICT), which can be used for the purpose of measuring to what extent students can understand the written content involving 8th grade science items of SBS (national placement test), and determine its psychometric properties. In this survey study, 259 eighth grade students enrolled in elementary schools in Antalya constituted the participants. SICT was developed with thirty reading comprehension items with science items of SBS implemented in 2012 and 2013. Field experts’ opinions were asked and necessary corrections were made based on experts’ feedbacks. In order to determine psychometric properties of instrument, exploratory and confirmatory factor analyses were carried out with data collected from the research group. In accordance with factor analyses and results related to item discrimination, nine items were excluded from instrument, and the instrument took its final form with twenty one items. Results of exploratory and confirmatory factor analyses revealed that within the scope of single-factor structure, construct validity is high for target characteristics to be measured. In addition, reliability of scores acquired with SICT is high with regard to internal consistency.

Extra-linguistic influences on sentence comprehension in Italian-speaking children with and without specific language impairment.

Many children with specific language impairment (SLI) in sentence comprehension. These deficits are usually attributed to limitations in the children's understanding of syntax or the lexical items contained in the sentences. This study examines the role that extra-linguistic factors can play in these children's sentence comprehension. Extra-linguistic demands on sentence comprehension are manipulated directly by varying the nature of the materials used. Forty-five Italian-speaking children participated: 15 with SLI (mean age = 4;5), 15 typically developing children matched for age (TD-A, mean age = 4;5), and 15 younger typically developing children matched according to language comprehension test scores (TD-Y, mean age = 3;9). The children responded to sentence comprehension items that varied in their length and/or the number and type of foils that competed with the target picture. The TD-A children were more accurate than the TD-Y children and the children with SLI, but, for all groups, accuracy declined when task demands increased. In particular, sentences containing superfluous adjectives (e.g., Il topo bello copre l'uccello allegro, 'The nice mouse covers the happy bird' where all depicted mice were nice and all birds were happy) yielded higher scores than similar sentences in which each adjective had to be associated with the proper character (e.g., Il cane giallo lava il maiale bianco, 'The yellow dog washes the white pig', where foils included a yellow dog washing a pink pig, and a brown dog washing a white pig). Many errors reflected recency effects, probably influenced by the fact that adjectives modifying the object appear at the end of the sentence in Italian. Differences between conditions were observed even when lexical content, syntactic structure and sentence length were controlled. This finding suggests the need for great care when assessing children's comprehension of sentences. The same syntactic structure and lexical content can vary in difficulty depending on the number and types of foils used in combination with the target picture.

Measuring nursing informatics competencies of practicing nurses in Korea: Nursing Informatics Competencies Questionnaire.

Informatics competencies are a necessity for contemporary nurses. However, few researchers have investigated informatics competencies for practicing nurses. A full set of Informatics competencies, an instrument to measure these competencies, and potential influencing factors have yet to be identified for practicing nurses. The Nursing Informatics Competencies Questionnaire was designed, tested for psychometrics, and used to measure beginning and experienced levels of practice. A pilot study using 54 nurses ensured item comprehension and clarity. Internal consistency and face and content validity were established. A cross-sectional survey was then conducted on 230 nurses in Seoul, Korea, to determine construct validity, describe a complete set of informatics competencies, and explore possible influencing factors on existing informatics competencies. Principal components analysis, descriptive statistics, and multiple regression were used for data analysis. Principal components analysis gives support for the Nursing Informatics Competencies Questionnaire construct validity. Survey results indicate that involvement in a managerial position and self-directed informatics-related education may be more influential for improving informatics competencies, whereas general clinical experience and workplace settings are not. This study provides a foundation for understanding how informatics competencies might be integrated throughout nurses' work lives and how to develop appropriate strategies to support nurses in their informatics practice in clinical settings.

Monitoring the health of transgender and other gender minority populations: validity of natal sex and gender identity survey items in a U.S. national cohort of young adults.

BackgroundA barrier to monitoring the health of gender minority (transgender) populations is the lack of brief, validated tools with which to identify participants in surveillance systems.MethodsWe used the Growing Up Today Study (GUTS), a prospective cohort study of U.S. young adults (mean age = 20.7 years in 2005), to assess the validity of self-report measures and implement a two-step method to measure gender minority status (step 1: assigned sex at birth, step 2: current gender identity). A mixed-methods study was conducted in 2013. Construct validity was evaluated in secondary data analysis of the 2010 wave (n = 7,831). Cognitive testing interviews of close-ended measures were conducted with a subsample of participants (n = 39).ResultsCompared to cisgender (non-transgender) participants, transgender participants had higher levels of recalled childhood gender nonconformity age < 11 years and current socially assigned gender nonconformity and were more likely to have ever identified as not completely heterosexual (p < 0.001). No problems with item comprehension were found for cisgender or gender minority participants. Assigned sex at birth was interpreted as sex designated on a birth certificate; transgender was understood to be a difference between a person’s natal sex and gender identity. Participants were correctly classified as male, female, or transgender.ConclusionsThe survey items performed well in this sample and are recommended for further evaluation in languages other than English and with diverse samples in terms of age, race/ethnicity, and socioeconomic status.

Development of a questionnaire encompassing indicators of distress: A tool for use with women in surgical continuity of care for breast cancer

PurposeWomen with breast cancer often experience significant distress. Currently, there are no questionnaires aimed at identifying women's unique and possible changing indicators for distress in surgical continuity of care for breast cancer. We developed and tested three questionnaires specifically for this use. Methods and sampleWe first searched PubMed, CINAHL and PsycINFO to retrieve information on previously described indicators. Next, we conducted a focus group interview with 6 specialised nurses, who have extensive experience about consequences of breast cancer for women in surgical continuity of care. The questionnaire was tested on 18 women scheduled for breast cancer surgery. Subsequently, the women were debriefed to gain knowledge about comprehensibility, readability and relevance of items, and the time needed to complete the questionnaire. After adjustment, the questionnaires were field-tested concomitantly with a clinical study, which both consisted of a survey and an interview study. Key resultsThree multi-item questionnaires were developed specific to different time points in surgical continuity of care. The questionnaires share a core of statements divided into seven sub-scales: emotional and physical situation, social condition, sexuality, body image, religion and organisational factors. Besides the core of statements, each questionnaire has different statements depending on the time point of surgical continuity of care when it was to be responded to. ConclusionThe questionnaires contain comprehensive items that can identify indicators for distress in individual women taking part in surgical continuity of care. The items were understandable and the time used for filling in the questionnaires was reasonable.

From One to Multiple Accents on a Test of L2 Listening Comprehension

Concerns about the need for assessing multidialectal listening skills for global contexts are becoming increasingly prevalent. However, the inclusion of multiple accents on listening assessments may threaten test fairness because it is not practical to include every accent that may be encountered in the language use domain on these tests. Given this dilemma, this study aimed to determine the extent to which accent strength and familiarity affect comprehension and to provide a defensible direction for assessing multidialectal listening comprehension. A strength of accent scale was developed, and one US, four Australian, and four British English speakers of English were selected based on a judgment of their strength of accent. Next, TOEFL test takers (N = 21,726) were randomly assigned to listen to a common lecture given by one of the nine selected speakers, and respond to six comprehension items and a survey designed to assess their familiarity with various accents. The results suggest that strength of accent and familiarity do affect listening comprehension, and these factors affect comprehension even with quite light accents.

Creating on Persistence Mapping File for Vocabulary Comprehension Item Bank of English Network Examination

Network examination extends the meaning of the traditional examination, makes the examination more fair, more authoritative and reliable, accord with the modern education system, and represents the development direction of modern education examination. In order to solve the problems of the present situation that students’ scoring rate lower on the part of English vocabulary comprehension, develops a vocabulary comprehension item bank of English network examination. According to the data persistence mapping file to launch the research. Firstly, begins the design of database logical structure, designed the logical structure of "Examination question Main table", "Alternative vocabulary table" and "Standard answer table"; Then, begins the design of persistence mapping file, designs the database tables and data operation class corresponding to the mapping file which is based on NHibernate architecture. The research contents of this paper laid the foundation for the construction of item bank.

Assessing health literacy of hypertensive patients in a primary care setting using a self-administered questionnaire.

The Newest Vital Sign (NVS) assesses health literacy in clinical settings. This exploratory study examined the feasibility of using the NVS as a self-administered questionnaire (SAQ) in a low-income, primary care setting. Adult hypertensive patients were recruited in 2011-2012 (n=238). Quantitative and qualitative analyses were conducted to examine potential issues with self-administration. Patients had low rates of adequate health literacy (28.4%). Only half of respondents completed the NVS (54.4%). Being Black, female, and having additional chronic illnesses increased the likelihood of being a partial responder as opposed to being a completer. Easier math problems and reading comprehension items were attempted in greater numbers by partial responders. Results indicate issues with interpretation and the need for better scoring instructions. Future studies that self-administer the NVS should consider slight modifications. The NVS provides important information about patients' health literacy and it is a valuable tool to assess patients' understanding of food labels.