Assessing health numeracy among community-dwelling older adults

Quantitative information occupies a central role within health care decision making. Despite this, numeracy has attracted little research attention. Therefore, the purpose of this study was to (1) describe the health numeracy skill of a nonclinical, Canadian community-based senior population and (2) determine the relationship between health numeracy skill and prose health literacy, education, and math anxiety in this population. A convenience sample of 140 men and women, 50 + years, completed a questionnaire assessing demographic details, math anxiety, functional health literacy (Shortened Test of Functional Health Literacy for Adults STOFHLA), general context numeracy, and health context numeracy skills. Most participants had adequate functional health literacy (prose and numeracy) as measured by the STOFHLA, poorer general context numeracy skill, higher health context numeracy skill, and moderate math anxiety. Approximately 36% of the variation in general context numeracy scores and 26% of the variation in health context numeracy scores were explained by prose health literacy skill (STOFHLA), math anxiety, and attained education. This research offers an initial assessment of health numeracy skills as measured by three existing numeracy scales among a group of independently functioning older Canadian adults. This work highlights the need for clarification of the numeracy concept and refinement of health numeracy assessment instruments. Moreover, identifying patients' numeracy strengths and weaknesses will enable the development of focused numeracy interventions and may contribute to moving individuals further along the continuum of health literacy proficiency.     

Health literacy explains racial disparities in diabetes medication adherence

Although low health literacy and suboptimal medication adherence are more prevalent in racial/ethnic minority groups than Whites, little is known about the relationship between these factors in adults with diabetes, and whether health literacy or numeracy might explain racial/ethnic disparities in diabetes medication adherence. Previous work in HIV suggests health literacy mediates racial differences in adherence to antiretroviral treatment, but no study to date has explored numeracy as a mediator of the relationship between race/ethnicity and medication adherence. This study tested whether health literacy and/or numeracy were related to diabetes medication adherence, and whether either factor explained racial differences in adherence. Using path analytic models, we explored the predicted pathways between racial status, health literacy, diabetes-related numeracy, general numeracy, and adherence to diabetes medications. After adjustment for covariates, African American race was associated with poor medication adherence (r = -0.10, p < .05). Health literacy was associated with adherence (r = .12, p < .02), but diabetes-related numeracy and general numeracy were not related to adherence. Furthermore, health literacy reduced the effect of race on adherence to nonsignificance, such that African American race was no longer directly associated with lower medication adherence (r = -0.09, p = .14). Diabetes medication adherence promotion interventions should address patient health literacy limitations.     

The Role of Health Literacy and Numeracy in Contraceptive Decision-Making for Urban Chicago Women

Low functional health literacy and numeracy have known associations with poor health outcomes, yet little work has investigated these markers of health disparity in a family planning population. We used an in-depth qualitative process and 2 literacy and numeracy assessment tools, the REALM-7 and the Schwartz numeracy scale, to assess the role of literacy and numeracy in contraceptive decision-making in an urban Chicago population. Brief surveys and semi-structured interviews were conducted with 30 postpartum women who had received Medicaid-funded care at an obstetrics clinic in an academic medical center. In-person one-on-one interviews were then reviewed for themes using an iterative process. Qualitative analysis techniques identifying emergent themes were applied to interview data. Literacy and numeracy were assessed using REALM-7 and a validated 3-question numeracy scale. In this cohort of African American (63 %) and Hispanic (37 %) women (median age 26), 73 % had unplanned pregnancies. Although health literacy rates on the REALM-7 were adequate, numeracy scores were low. Low literacy and numeracy scores were associated with interview reports of poor contraceptive knowledge and difficulty with contraceptive use. Low health literacy and numeracy may play an important role in contraception decision-making in this low-income, minority population of women. We recommend further study of literacy and numeracy in a family planning population. Comprehensive contraception education and communication around the contraceptive decision-making process should take place at literacy and numeracy levels appropriate to each individual.     

Health Literacy,Numeracy, and Other Characteristics Associated With Hospitalized Patients' Preferences for Involvement in Decision Making

Little research has examined the association of health literacy and numeracy with patients' preferred involvement in the problem-solving and decision-making process in the hospital. Using a sample of 1,249 patients hospitalized with cardiovascular disease from the Vanderbilt Inpatient Cohort Study (VICS), we assessed patients' preferred level of involvement using responses to two scenarios of differing symptom severity from the Problem-Solving Decision-Making Scale. Using multivariable modeling, we determined the relationship of health literacy, subjective numeracy, and other patient characteristics with preferences for involvement in decisions, and how this differed by scenario. The authors found that patients with higher levels of health literacy desired more participation in the problem-solving and decision-making process, as did patients with higher subjective numeracy skills, greater educational attainment, female gender, less perceived social support, or greater health care system distrust (p < .05 for each predictor in multivariable models). Patients also preferred to participate more in the decision-making process when the hypothetical symptom they were experiencing was less severe (i.e., they deferred more to their physician when the hypothetical symptom was more severe). These findings underscore the role that patient characteristics, especially health literacy and numeracy, play in decisional preferences among hospitalized patients.     

Health Literacy,Numeracy, and Graphical Literacy Among Veterans in Primary Care and Their Effect on Shared Decision Making and Trust in Physicians

Studies reveal high levels of inadequate health literacy and numeracy in African Americans and older veterans. The authors aimed to investigate the distribution of health literacy, numeracy, and graph literacy in these populations. They conducted a cross-sectional survey of veterans receiving outpatient care and measured health literacy, numeracy, graph literacy, shared decision making, and trust in physicians. In addition, the authors compared subgroups of veterans using analyses of covariance. Participants were 502 veterans (22–82 years). Low, marginal, and adequate health literacy were found in, respectively, 29%, 26%, and 45% of the veterans. The authors found a significant main effect of race qualified by an age and race interaction. Inadequate health literacy was more common in African Americans than in Whites. Younger African Americans had lower health literacy (p <.001), graph literacy (p <.001), and numeracy (p <.001) than did Whites, even after the authors adjusted for covariates. Older and younger participants did not differ in health literacy, objective numeracy, or graph literacy after adjustment. The authors found no health literacy or age-related differences regarding preferences for shared decision making. African Americans expressed dissatisfaction with their current role in decision making (p =.03). Older participants trusted their physicians more than younger participants (p =.01). In conclusion, African Americans may be at a disadvantage when reviewing patient education materials, potentially affecting health care outcomes.     

What Do Healthy Women Know about the Consequences of Delayed Childbearing?

Female fertility declines dramatically with age, and childbearing at older maternal ages has significant medical consequences for mother and infant that are well-known to health professionals. Despite this, the average maternal age in the United States continues to rise. Many factors likely contribute to this secular trend; to date, no research has examined whether American women are aware of the complications of deferring conception and how this correlates with health literacy. The purpose of this study was to evaluate women's knowledge of the implications of delaying pregnancy. A structured, in-person interview was administered to 300 women between 20 and 50 years of age attending 1 of 2 gynecologic clinics at a single institution. Demographic information, medical history, and gynecologic history were obtained; and participants answered questions about the implications of aging for fertility and pregnancy outcome. Health literacy and numeracy were assessed. Participants demonstrated knowledge deficits about the implications of aging on fertility and pregnancy, and many were unfamiliar with success rates of infertility treatments. Several demographic factors correlated with knowledge; health literacy and numeracy were both important predictive variables. To the authors' knowledge, this is the first study of women's knowledge about fertility, aging, and their health literacy. Awareness of the importance of health literacy and numeracy should inform future educational efforts about fertility.     

Patients' literacy skills: more than just reading ability

Limited literacy contributes to suboptimal care and outcomes for patients. The Institute of Medicine noted that future work in health literacy should consider multiple literacy skills. However, lacking empirical evidence of the relationship between different literacy skills, reading skills are often used as proxies of literacy in research and practice. Using a community-based sample of 618 individuals residing in Boston, Massachusetts, and Providence, Rhode Island, the authors conducted a principal component analysis on measures of four literacy skills--reading, numeracy, oral (speaking), and aural (listening)--to examine whether and to what extent literacy can, or should, be represented by a single measure. The first principal component represented overall literacy and could only explain 60% of the total variation in literacy skills among individuals. The second principal component differentiated between numeracy/reading and the oral/aural exchange. While reading and numeracy best represent overall literacy, patients' relative strengths may vary. Those with moderate reading ability may have high oral and aural language skills. Conversely, people who have difficulties speaking with or understanding a provider may read well. Effective communication with patients should rely on the oral exchange and written health information, and not rely on a single literacy skill.     

Patients' Literacy Skills: More Than Just Reading Ability

Limited literacy contributes to suboptimal care and outcomes for patients. The Institute of Medicine noted that future work in health literacy should consider multiple literacy skills. However, lacking empirical evidence of the relationship between different literacy skills, reading skills are often used as proxies of literacy in research and practice. Using a community-based sample of 618 individuals residing in Boston, Massachusetts, and Providence, Rhode Island, the authors conducted a principal component analysis on measures of four literacy skills—reading, numeracy, oral (speaking), and aural (listening)—to examine whether and to what extent literacy can, or should, be represented by a single measure. The first principal component represented overall literacy and could only explain 60% of the total variation in literacy skills among individuals. The second principal component differentiated between numeracy/reading and the oral/aural exchange. While reading and numeracy best represent overall literacy, patients' relative strengths may vary. Those with moderate reading ability may have high oral and aural language skills. Conversely, people who have difficulties speaking with or understanding a provider may read well. Effective communication with patients should rely on the oral exchange and written health information, and not rely on a single literacy skill.     

Perspective: the role of numeracy in health care

Numeracy, the "ability to understand and use numbers in daily life" is an important but understudied component of literacy. Numeracy-related tasks are common in health care and include understanding nutrition information, interpreting blood sugar readings and other clinical data, adjusting medications, and understanding probability in risk communication. While literacy and numeracy are strongly correlated, we have identified many patients with adequate reading ability but poor numeracy skills. Better tools to measure numeracy and more studies to assess the unique contribution of numeracy are needed. This research can contribute to developing interventions to improve outcomes for patients with poor numeracy.     

Public Health Literacy Defined

Public health literacy is an emerging concept necessary to understand and address the broad array of factors, such as climate change, globalization, and poverty, that influence the public's health. Whereas health literacy has traditionally been operationalized as an individual-level construct, public health literacy takes into account the complex social, ecologic, and systemic forces affecting health and well-being. However, public health literacy has not yet been fully articulated. This paper addresses this gap by outlining a broad, new definition of public health literacy. This definition was developed through an inductive analytic process conducted in 2007 by a multidisciplinary research team, and two expert-panel sessions were convened to assess the consensual validity of the emergent definition. Based on this process, public health literacy is defined as the degree to which individuals and groups can obtain, process, understand, evaluate, and act on information needed to make public health decisions that benefit the community. Three dimensions of public health literacy—conceptual foundations, critical skills, and civic orientation—and related competencies are also proposed. Public health literacy is distinct from individual-level health literacy, and together, the two types of literacy form a more comprehensive model of health literacy. A five-part agenda is offered for future research and action aimed at increasing levels of public health literacy.     

Defining and measuring health literacy: how can we profit from other literacy domains?

When the antecedents of health-promoting behavior are explored, the concept of health literacy is deemed a factor of major influence. Originally defined as reading, writing and numeracy skills in the health domain, health literacy is now considered a multidimensional concept. The ongoing discussion on health literacy reveals that no agreement exists about which dimensions to include in the concept. To contribute to the development of a consistent and parsimonious concept of health literacy, we conducted a critical review of concepts in other literacy domains. Our review was guided by two research questions: (i) Which dimensions are included in the concepts of other literacy domains? (ii) How can health literacy research profit from other literacy domains? Based on articles collected from PubMed, PsycINFO, Communication & Mass Media Complete, CINAHL, SAGE Full-Text Collection, Cochrane Library and Google Scholar as well as selected monographs and editions, we identified seven distinct dimensions. Some of the dimensions recur across all reviewed literacy domains and first attempts have been made to operationalize the dimensions. Expanding upon these dimensions, the paper discusses how they can prove useful for elaborating a consistent and parsimonious concept of health literacy and foster the development of a more holistic measure.     

The association of understanding of medical statistics with health information seeking and health provider interaction in a national sample of young adults

Numeracy, or, "the ability to use and understand numbers in daily life" is a critical component of health literacy. However, little research has focused on numeracy in young adults (ages 18-29). We used a national sample to examine how health-information seeking, trust in sources, and interactions with health care providers differ for young adults with lower and higher numeracy. We included respondents ages 18 to 29 (n = 661) from the latest administration (2008) of the Health Information National Trends Survey (HINTS). There were no significant differences between those with lower and higher numeracy for most sociodemographic variables, nor did numeracy predict trust in health information sources. However, there were several differences for health-information seeking and health-provider interactions. Those with lower numeracy were significantly more likely to say their most recent search took a lot of effort (46% vs. 24%, p = .0008) and was frustrating (45% vs. 22%, p = .0038). Those in the lower numeracy group also reported more negative interactions with health providers, including feeling less able to rely on their provider (62% vs. 86%, p < .0001), and less likely to say their provider made sure they understood information (70% vs. 88%, p = .0001) and helped with any uncertainty (51% vs. 75%, p < .0001), even when adjusting for other variables. Our data suggest that limited comfort with numbers and statistics can influence a variety of health-related factors for young adults. More research is needed to understand how health literacy skills--including numeracy--influence health-information seeking, patient-provider relationships, and health outcomes, for young adults.     

The evolving concept of health literacy

The relationship between poor literacy skills and health status is now well recognized and better understood. Interest in this relationship has led to the emergence of the concept of health literacy. The concept has emerged from two different roots - in clinical care and in public health. This paper describes the two distinctive concepts that reflect health literacy, respectively, as a clinical "risk", or a personal "asset". In the former case a strong science is developing to support screening for poor literacy skills in clinical care and this is leading to a range of changes to clinical practice and organization. The conceptualization of health literacy as an asset has its roots in educational research into literacy, concepts of adult learning, and health promotion. The science to support this conceptualization is less well developed and is focused on the development of skills and capacities intended to enable people to exert greater control over their health and the factors that shape health. The paper concludes that both conceptualizations are important and are helping to stimulate a more sophisticated understanding of the process of health communication in both clinical and community settings, as well as highlighting factors impacting on its effectiveness. These include more personal forms of communication and community based educational outreach. It recommends improved interaction between researchers working within the two health literacy perspectives, and further research on the measurement of health literacy. The paper also emphasizes the importance of more general strategies to promote literacy, numeracy and language skills in populations.     

The evolving concept of health literacy

The relationship between poor literacy skills and health status is now well recognized and better understood. Interest in this relationship has led to the emergence of the concept of health literacy. The concept has emerged from two different roots – in clinical care and in public health. This paper describes the two distinctive concepts that reflect health literacy, respectively, as a clinical “risk”, or a personal “asset”. In the former case a strong science is developing to support screening for poor literacy skills in clinical care and this is leading to a range of changes to clinical practice and organization. The conceptualization of health literacy as an asset has its roots in educational research into literacy, concepts of adult learning, and health promotion. The science to support this conceptualization is less well developed and is focused on the development of skills and capacities intended to enable people to exert greater control over their health and the factors that shape health.The paper concludes that both conceptualizations are important and are helping to stimulate a more sophisticated understanding of the process of health communication in both clinical and community settings, as well as highlighting factors impacting on its effectiveness. These include more personal forms of communication and community based educational outreach. It recommends improved interaction between researchers working within the two health literacy perspectives, and further research on the measurement of health literacy. The paper also emphasizes the importance of more general strategies to promote literacy, numeracy and language skills in populations.     

儿童青少年健康素养研究现状与进展

提升健康素养可以有效降低儿童青少年发生健康危险行为和不良健康结局的风险。近年来全球关于儿童青少年健康素养的研究呈逐年上升趋势，对已有研究进行综述，发现目前尚未检索到通用的儿童青少年健康素养定义和内涵，且各国多采用成人健康素养代替或做适当调整，未充分考虑儿童青少年的阶段性发展特征及独特健康需求；评价指标体系和工具多样化，也使得研究结果可比性不足，难以得到一致、可靠的研究结论。未来需继续探讨提出更为全面和实用的定义及内涵，并研制可推广至全国的标准化评价工具。     

"I cried because I didn't know if I could take care of him": toward a taxonomy of interactive and critical health literacy as portrayed by caregivers of children with special health care needs

Although the contributions of reading ability and numeracy skills in successful navigation of health-related systems are understood, the skills that comprise interactive and critical health literacy are not fully explicit. Using a phenomenological approach and the conceptual frame of health literacy as an asset, we conducted focus group interviews with 35 caregivers of children who had significant medical needs. Caregiver quotes were coded and categorized and then compared to the Revised Blooms Taxonomy. The purpose of the analysis was to better understand the interactive and critical health literacy skills caregivers use when coordinating their children's care. The findings support a dynamic constructivist perspective of health literacy such that caregiver skill changed relative to the children's health conditions. In addition, a taxonomic code of cognitive and communicative skills emerged from the data. This taxonomy may be useful in developing instrumentation to measure interactive and critical health literacy as well as in identifying a potential foci of interventions aimed at improving interactive and critical health literacy.     

Nutrition and health literacy: a systematic review to inform nutrition research and practice

Health literacy is defined as the degree to which individuals obtain, process, and understand basic health information and services to make informed health decisions. Health literacy is a stronger predictor of health than age, income, employment, education, and race. Although the field has grown during the past decade, most health literacy research does not explicitly focus on food or nutrition, and dietetics practitioners often remain unaware of patients' health literacy level. The purpose of this systematic review was to summarize the literature on nutrition and health literacy to enhance dietetics practitioners' awareness of the importance of health literacy in practice and research. Of the 33 studies reviewed, four focused on measurement development, 16 on readability assessments, and 13 on individual literacy skills assessments. Collective evaluation revealed four noteworthy gaps, including the need to use more comprehensive assessment approaches that move beyond readability and numeracy to address the full spectrum of health literacy factors; the need to apply more robust experimental studies to examine the effectiveness of health literacy interventions among individuals, communities, health care providers, and health care systems; the need to explore the moderating and mediating roles of an individual's health literacy status on nutrition outcomes; and the need to examine long-term effects of health literacy interventions on nutrition outcomes. This article defines health literacy gaps and opportunities in nutrition research and practice, and calls for continued action to elevate the role of dietetics practitioners in addressing health literacy.     

The Effect of Narrative Information in a Publicly Available Patient Decision Aid for Early-Stage Breast Cancer

This study was designed to (1) evaluate the effect of narratives used in a popular, publicly available patient decision aid for early-stage breast cancer on hypothetical treatment decisions and attitudes toward the decision aid and (2) explore the moderating effects of participant numeracy, electronic health literacy and decision-making style. Two hundred women were asked to imagine that they had been diagnosed with early-stage breast cancer and viewed one of two versions of a video decision aid for early-stage breast cancer. The narrative version of the aid included stories from breast cancer survivors; the control version had no patient stories. After viewing the video decision aid, participants made a hypothetical treatment choice between lumpectomy with radiation and mastectomy, answered several questions about their decision, and evaluated the quality of the decision aid. Participants received $100 for completing the study. The two conditions differed in their motivations for the treatment decision and perceptions of the aid's trustworthiness and emotionality but showed no differences in preferences for surgical treatments or evaluations of the decision aid's quality. However, the impact of patient narratives was moderated by numeracy and electronic health literacy. Higher levels of numeracy were associated with decreased decisional confidence and lower ratings of trustworthiness for the decision aid in the narrative video condition but not in the control video condition. In contrast, higher levels of electronic health literacy were associated with increased decisional confidence and greater perceptions of trustworthiness and credibility of the decision aid in the narrative video condition but not the control video condition.     

Understanding health literacy: an expanded model

A long and yet unfinished history of investigating how individual capabilities and social processes explain or predict health indicates that poor education, low literacy, poor health and early death are strongly linked around the world. However, the complexity of those relationships is not fully understood. In this article, we propose an expanded model of health literacy characterized by four domains: fundamental literacy (reading, writing, speaking and numeracy), science literacy, civic literacy and cultural literacy. To explore the utility of this model, we examine selected pieces of the public discourse about terrorism and bioterrorism that dominated the mass media during the anthrax threat in the United States during 2001. We conclude that this model of health literacy is useful to analyze health communication, to aid in constructing more understandable and appropriate health communication, and ultimately can lead to the development of a new measure to assess health literacy skills in individuals.