Health numeracy: the importance of domain in assessing numeracy

Validation and Psychometric Evaluation of Diabetes Literacy, Numeracy, and Knowledge Tools in the Arabic Context

PURPOSE

The purpose of this study was to validate the Literacy Assessment for Diabetes (LAD), the Diabetes Numeracy Test (DNT), and the Simplified Diabetes Knowledge Test (DKT) in the Arabic language and context.

METHODS

Three hundred eighty four, ≥18-year-old patients with type 1, type 2, or gestational diabetes mellitus were recruited from 3 endocrinology clinics in the United Arab Emirates. Exploratory factor analysis using principal component was performed. Achieved scores were compared using Pearson bivariate correlation.

RESULTS

All 60 LAD items loaded on 1 factor accounting for 66.7% of the variance, with internal consistency α = .991. Average score = 68.7%. Nineteen out of 26 items were retained on the DNT and grouped into 4 factors, prescription reading and directions, proper dose coverage, nutrition, and insulin, with good internal consistency (α = .721). Average score = 73.2%. All 20 DKT items loaded on 3 factors accounting for 41.2% of the variance, causes and consequences of the high blood sugar level, prevention of the disease, and misconceptions about diabetes self-management, with good internal consistency (α = .799). Average score = 71.9%. A moderate and significant correlation between the DKT and DNT (r = .56, P < .001) was observed.

CONCLUSIONS

Three tools to assess diabetes literacy, numeracy, and knowledge were psychometrically tested to establish their validity and reliability in the Arabic language and context. The tools could be used to assess patient skills and competence in navigating the health care system and managing their diabetes.

Basic Symbolic Number Skills, but Not Formal Mathematics Performance, Longitudinally Predict Mathematics Anxiety in the First Years of Primary School

Mathematical anxiety (MA) and mathematics performance typically correlate negatively in studies of adolescents and adults, but not always amongst young children, with some theorists questioning the relevance of MA to mathematics performance in this age group. Evidence is also limited in relation to the developmental origins of MA and whether MA in young children can be linked to their earlier mathematics performance. To address these questions, the current study investigated whether basic and formal mathematics skills around 4 and 5 years of age were predictive of MA around the age of 7-8. Additionally, we also examined the cross-sectional relationships between MA and mathematics performance in 7-8-year-old children. Specifically, children in our study were assessed in their first (T1; aged 4-5), second (T2; aged 5-6), and fourth years of school (T3; aged 7-8). At T1 and T2, children completed measures of basic numerical skills, IQ, and working memory, as well as curriculum-based mathematics tests. At T3, children completed two self-reported MA questionnaires, together with a curriculum-based mathematics test. The results showed that MA could be reliably measured in a sample of 7-8-year-olds and demonstrated the typical negative correlation between MA and mathematical performance (although the strength of this relationship was dependent on the specific content domain). Importantly, although early formal mathematical skills were unrelated to later MA, there was evidence of a longitudinal relationship between basic early symbolic number skills and later MA, supporting the idea that poorer basic numerical skills relate to the development of MA.

Extending the purview of risk perception attitude (RPA) framework to understand health insurance-related information seeking as a long-term self-protective behavior

Objective: The purpose of this study is to examine the roles of risk perceptions and efficacy beliefs play in predicting emerging adults' health insurance information seeking behavior based on the risk perception attitude (RPA) framework. In addition, the current study tests a role of worry to elucidate an underlying mechanism of their health insurance information seeking behavior. Participants: A total of 694 participants was recruited from a large public university in Southwest, USA. Methods: Participants completed an online survey questionnaire. Results: Efficacy beliefs influenced health insurance-related information seeking behavior. An intriguing finding is that there were significant differences in worry across the attitudinal groups posited in the RPA framework, which is consistent with findings in prior literature. Conclusions: Information about health insurance helps individuals make good decisions for their health in a long-term perspective, which is the primary interest of the RPA framework and the current study. The findings would provide resources for designing effective communication materials to help human beings improve their well-being and prepare for their well-ending. This communication effort would contribute to ensuring public health safety, reducing health disparities, and enhancing a society's well-being.

Maternal health literacy and health numeracy conceptualizations in public health: A scoping review

Despite unprecedented advancement in educational opportunities and access to information, maternal health literacy (MHL) and health numeracy (HN) skills remain low in North America. By enhancing MHL, the educated civic public-those who have the capacity, skills, and knowledge to apply prose and numerical health information-engages more proactively in public health practice. The purpose of this scoping review was to map the existing empirical evidence on MHL to work toward a better understanding of the practical implications for public health. We explored MHL and HN through the following research question: "How are maternal health literacy and health numeracy conceptualised in public health planning, implementation, and evaluation?" First, we employed a five-stage methodological framework for scoping reviews and used PRISMA-P to systematically identify eligible articles. Then, we used thematic analysis and an inductive approach guided by the research aims to identify themes related to how MHL and HN are conceptualised in empirical studies and developed an evidence table. Finally, two different reviewers coded articles using an inductive approach into six themes. We identified 1733 articles through a systematic search of five databases. After screening all the articles, 52 articles were included for thematic analysis. The final themes were: (i) sociocultural demographics; (ii) self-efficacy; (iii) communication; (iv) information seeking and operationalisation; (v) health status; and (vi) reasoning. The research evidence demonstrated limitations concerning the impact of sociocultural background on a mother's recognition of health problems and the extent of which patient-centred care is culturally and linguistically appropriate. The research evidence revealed an opportunity to address the sociocultural linguistic experience of mothers within public health practice. Our research team supports moving away from the biomedical model of evidence-based medicine and adopting evidence-based practice ensures healthcare providers develop a holistic understanding of the maternal health needs of socioculturally diverse mothers.

Heterogeneity in how women value risk-stratified breast screening

PURPOSE

Risk-stratified screening has potential to improve the cost effectiveness of national breast cancer screening programs. This study aimed to inform a socially acceptable and equitable implementation framework by determining what influences a woman's decision to accept a personalized breast cancer risk assessment and what the relative impact of these key determinants is.

METHODS

Multicriteria decision analysis was used to elicit the relative weights for 8 criteria that women reported influenced their decision. Preference heterogeneity was explored through cluster analysis.

RESULTS

The 2 criteria valued most by the 347 participants related to program access, "Mode of invitation" and "Testing process". Both criteria significantly influenced participation (P < .001). A total of 73% preferred communication by letter/online. Almost all women preferred a multidisease risk assessment with potential for a familial high-risk result. Four preference-based subgroups were identified. Membership to the largest subgroup was predicted by lower educational attainment, and women in this subgroup were concerned with program access. Higher relative perceived breast cancer risk predicted membership to the smallest subgroup that was focused on test parameters, namely "Scope of test" and "Test specificity".

CONCLUSION

Overall, Australian women would accept a personalized multidisease risk assessment, but when aligning with their preferences, it will necessitate a focus on program access and the development of online communication frameworks.

What mathematical competencies does a citizen need to interpret Mexico's official information about the COVID-19 pandemic?

We report a study on mathematical literacy with special emphasis on health literacy. In particular, we identify and characterize the mathematical competencies that a citizen needs to interpret the official information on the COVID-19 pandemic as experienced in Mexico. To achieve this, we analyze the daily reports on the pandemic issued by the Mexican Ministry of Health, using the framework of mathematical competencies as a theoretical lens. Our results show that there are five necessary competencies to interpret the official information: mathematical communication, mathematical representation, mathematical symbols and formalism, mathematical modeling, and mathematical reasoning competency. After characterizing and illustrating these competencies, we close the paper with a reflection on the importance of mathematical literacy in a pandemic world.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10649-021-10082-9.

The Modest Effects of Fact Boxes on Cancer Screening

As health care becomes increasingly personalized to the needs and values of individual patients, informational interventions that aim to inform and debias consumer decision-making are likely to become important tools. In a randomized controlled experiment, we explore the effects of providing participants with published fact boxes on the benefits and harms of common cancer screening procedures. Female participants were surveyed about breast cancer screening by mammography, while male participants were surveyed about prostate cancer screening by prostate-specific antigen (PSA) testing. For these screening procedures, we expect consumers to have overly optimistic prior beliefs about the benefits and harms. We find that participants update their beliefs about the net benefits of screening modestly, but we observe little change in their stated preferences to seek screening. Participants who scored higher on a numeracy test updated their beliefs about screening benefits more in response to the fact boxes than did participants who scored lower on the numeracy test.

Decision Making in Psychiatric Patients: A Qualitative Study with Focus Groups

INTRODUCTION

It has been said that mental illnesses are characterised by poor decision making; there is some neuroscientific evidence of specific alterations in performance in decision making tests, but little is known about how patients make choices about their own treatments.

METHODS

Focus groups with patients from two psychiatric clinics, with discourse analysis.

RESULTS

Five deductive categories (tools, capacity, therapeutic relationship, method and family and network), plus one additional category from the analysis (stigma), and 35 inductive (posterior) categories were considered. The categories are analysed and the findings presented.

CONCLUSIONS

Patients express a need for greater participation in decisions about their treatment, and a more symmetrical psychiatrist-patient relationship, involving families. Decisions may be changed due to stigma, barriers to treatment access, and previous experiences.

Health Numeracy and Relative Risk Comprehension in Perioperative Patients and Physicians

BACKGROUND

Helping patients to understand relative risks is challenging. In discussions with patients, physicians often use numbers to describe hazards, make comparisons, and establish relevance. Patients with a poor understanding of numbers-poor "health numeracy"-also have difficulty making decisions and coping with chronic conditions. Although the importance of "health literacy" in perioperative populations is recognized, health numeracy has not been well studied. Our aim was to compare understanding of numbers, risk, and risk modification between a patient population awaiting surgery under general anesthesia and attending physicians at the same center.

METHODS

We performed a single-center cross-sectional survey study to compare patients' and physicians' health numeracy. The study instrument was based on the Schwartz-Lipkus survey and included 3 simple health numeracy questions and 2 risk reduction questions in the anesthesiology domain. The survey was mailed to patients over the age of 18 scheduled for elective surgery under general anesthesia between June and September 2019, as well as attending physicians at the study center.

RESULTS

Two hundred thirteen of 502 (42%) patient surveys sent and 268 of 506 (53%) physician surveys sent were returned. Median patient score was 4 of 5, but 32% had a score of ≤3. Patients significantly overestimated their total scores by an average of 0.5 points (estimated [mean ± standard deviation (SD)] = 4.3 ± 1.2 vs actual 3.8 ± 1.3; P < .001). Health numeracy was significantly associated with higher educational level (gamma = 0.351; P < .001) and higher-income level (gamma = 0.397; P < .001). Physicians' health numeracy was significantly higher than the patients' (median [interquartile range {IQR}] = 5 [4-5] vs 4 [3-5]; P < .001). There was no significant difference between physicians' self-estimated and actual total numeracy score (mean ± SD = 4.8 ± 0.6 vs 4.7 ± 0.6; P = .372). Simple health numeracy (questions 1-3) was predictive of correct risk reduction responses (questions 4, 5) for both patients (gamma = 0.586; P < .001) and physicians (gamma = 0.558; P = .006).

CONCLUSIONS

Patients had poor health numeracy compared to physicians and tended to overrate their abilities. A small proportion of physicians also had poor numeracy. Poor health numeracy was associated with incomprehension of risk modification, suggesting that some patients may not understand treatment efficacy. These disparities suggest a need for further inquiry into how to improve patient comprehension of risk modification.

Understanding Health Risk Comprehension: The Role of Math Anxiety, Subjective Numeracy, and Objective Numeracy

Background. Numeracy skills are important for medical decision making as lower numeracy is associated with misinterpreting statistical health risks. Math anxiety, characterized by negative emotions about numerical tasks, and lower subjective numeracy (i.e., self-assessments of numerical competence) are also associated with poor risk comprehension. Objective. To explore independent and mediated associations of math anxiety, numerical ability, and subjective numeracy with risk comprehension and to ascertain whether their associations are specific to the health domain. Methods. Objective numeracy was measured with a 14-item test. Math anxiety and subjective numeracy were assessed with self-report scales. Risk comprehension was measured with a 12-item test. In experiment 1, risk comprehension items were limited to scenarios in the health domain. In experiment 2, participants were randomly assigned to receive numerically equivalent risk comprehension items in either a health or nonhealth domain. Results. Linear regression analyses revealed that individuals with higher objective numeracy were more likely to respond correctly to the risk comprehension items, as were individuals with higher subjective numeracy. Higher math anxiety was associated with a lower likelihood of correct responding when controlling for objective numeracy but not when controlling for subjective numeracy. Mediation analyses indicated that math anxiety may undermine risk comprehension in 3 ways, including through 1) objective numeracy, 2) subjective numeracy, and 3) objective and subjective numeracy in serial, with subjective numeracy mediating the association between objective numeracy and risk comprehension. Findings did not differ by domain. Conclusions. Math anxiety, objective numeracy, and subjective numeracy are associated with risk comprehension through unique pathways. Education initiatives for improving health risk comprehension may be most effective if jointly aimed at tackling numerical ability as well as negative emotions and self-evaluations related to numeracy.

Assessment of literacy and numeracy skills related to non-steroidal anti-inflammatory drug labels

Background:

Non-steroidal anti-inflammatory drugs are widely used and have a potential for over-the-counter misuse. Limited health literacy is associated with poor health outcomes. Identification of new strategies to assess literacy and numeracy could be useful in targeting effective education initiatives.

Objective:

To characterize numeracy and literacy skills related to non-steroidal anti-inflammatory drug labels in primary care patients.

Methods:

Patients were recruited and consented over an 8-month period after their regular primary care visit. Demographic information was collected and two instruments were administered to assess literacy and numeracy skills: (1) a medication label literacy instrument focused on non-steroidal anti-inflammatory drugs (MedLit-NSAID) and (2) a general healthy literacy-screening tool, the Newest Vital Sign. Two questions on the MedLit-NSAID instrument evaluated understanding of the Food and Drug Administration medication guide for non-steroidal anti-inflammatory drugs and the Food and Drug Administration approved over-the-counter label.

Results:

A total of 145 patients were enrolled. Mean MedLit-NSAID and Newest Vital Sign scores were 6.8 (scale range 0–8) and 4.2 (scale range 0–6), respectively. Higher education level was associated with higher scores for both tools (p ⩽ 0.05). Total MedLit-NSAID scores on average were higher in females compared with males (6.5 vs 6, p = 0.05). Patients with decreased kidney function (n = 18) had significantly lower MedLit-NSAID scores (p ⩽ 0.05). Test–retest scores were not significantly different for MedLit-NSAID (p = 0.32). The correlation between the tools was 0.54 and internal consistency MedLit-NSAID was 0.61.

Conclusion:

A medication information focused instrument provided specific information to assess health literacy related to non-steroidal anti-inflammatory drug labels. This information could be utilized to develop patient education initiatives for medication label comprehension.

Assessing the Demand for Micropensions among India's Poor

Using new data from a field experiment in India, we test hypotheses about micropension design in a poor population. We elicit demand for the basic micropension in addition to variants with different minimum withdrawal ages, government match rates, and options for lump sum withdrawal. A majority (80%) of respondents report interest in the micropension, and the amount they are willing to contribute would be enough to cover about 40% of expected old-age consumption. We find that prospective policyholders value the inability to access the assets until a particular age. We also find that they respond positively to the government match rate.

Should Health Numeracy Be Assessed Objectively or Subjectively?

INTRODUCTION

Because current evidence suggests that numeracy affects how people make decisions, it is an important factor to account for in studies assessing the effectiveness of medical decision support interventions. Subjective and objective numeracy assessment methods are available that vary in theoretical background, skills assessed, known relationship with decision making skills, and ease of implementation. The best way to use these tools to assess numeracy when conducting medical decision-making research is currently unknown.

METHODS

We conducted Internet surveys comparing numeracy assessments obtained using the subjective numeracy scale (SNS) and 5 objective numeracy scales. Each study participant completed the SNS and 1 objective numeracy measure. Following each assessment, participants indicated willingness to repeat the assessment and rated its user acceptability.

RESULTS

The overall response rate was 78%, resulting in a total sample size of 673. Spearman correlations between the SNS and the objective numeracy measures ranged from 0.19 to 0.44. Acceptability assessments for the short form of the Numeracy Understanding in Medicine Instrument and the SNS did not differ significantly. The other objective scales all had lower acceptability ratings than the SNS.

CONCLUSIONS

These findings are consistent with prior research suggesting that objective and subjective numeracy scales measure related but distinct constructs. Due to current uncertainty regarding which construct is more likely to influence the effectiveness of decision support interventions, these findings warrant further investigation to determine the proper use of objective versus subjective numeracy assessments in medical decision-making research. Pending additional information, a reasonable approach is to measure both objective and subjective numeracy so that the full range of actual and perceived numeracy skills can be taken into account.

Examining Associations between Health Information Seeking Behavior and Adult Education Status in the U.S.: An Analysis of the 2012 PIAAC Data

This paper presents data from the Program for the International Assessment of Adult Competencies with a focus on the interrelationships among health information seeking behavior (HISB), and health status or use of preventive health measures for U.S. adults both with and without a high school diploma. Key results of ordinal and binary logistic regression analyses indicated that, after controlling for demographic factors, (1) adults with a high school diploma use more text-based health information sources while adults without a high school diploma use more oral sources, (2) using the Internet as a source of health information is more strongly related to reporting excellent/very good health status than having a high school diploma, (3) those without a high school diploma who use the Internet report the largest increase in health status over any other health information source, and (4) for those with learning disability or vision problem, a high facility in reading English is an important predictor of whether the Internet is used as a health information source. The Internet appears to play a key role in both enhancing health status and enabling use of preventive measures for those with and without a high school diploma; although, individuals without a high school diploma who use the Internet for health information derive substantial benefit in health status.

Impact of a web-based treatment decision aid for early-stage prostate cancer on shared decision-making and health outcomes: study protocol for a randomized controlled trial

Background

At an early stage, prostate cancer patients are often eligible for more than one treatment option, or may choose to defer curative treatment. Without a pre-existing superior option, a patient has to weigh his personal preferences against the risks and benefits of each alternative to select the most appropriate treatment. Given this context, in prostate cancer treatment decision-making, it is particularly suitable to follow the principles of shared decision-making (SDM), especially with the support of specific instruments like decision aids (DAs). Although several alternatives are available, present tools are not sufficiently compatible with routine clinical practice. To overcome existing barriers and to stimulate structural implementation of DAs and SDM in clinical practice, a web-based prostate cancer treatment DA was developed to fit clinical workflow. Following the structure of an existing DA, Dutch content was developed, and values clarification methods (VCMs) were added. The aim of this study is to investigate the effect of this DA on (shared) treatment choice and patient-reported outcomes.

Methods/design

Nineteen Dutch hospitals are included in a pragmatic, cluster randomized controlled trial, with an intervention and a control arm. In the intervention group, the DA will be offered after diagnosis, and a summary of the patients’ preferences, which were identified with the DA, can be discussed by the patient and his clinician during later consultation. Patients in the control group will receive information and decisional support as usual. Results from both groups on decisional conflict, treatment choice and the experience with involvement in the decision-making process are compared. Patients are requested to fill in questionnaires after treatment decision-making but before treatment is started, and 6 and 12 months later. This will allow the development of treatment satisfaction, decisional regret, and quality of life to be monitored. Clinicians from both groups will evaluate their practice of information provision and decisional support.

Discussion

This study will describe a web-based prostate cancer treatment DA with VCMs. The effect of this DA on the decision-making process and subsequent patient reported outcomes will be evaluated.

Trial registration

The Netherlands National Trial Register: NTR4554, registration date 1 May 2014.

Health numeracy: perspectives about using numbers in health management from African American patients receiving dialysis

Health numeracy is linked to important clinical outcomes. Kidney disease management relies heavily on patient numeracy skills across the continuum of kidney disease care. Little data are available eliciting stakeholder perspectives from patients receiving dialysis about the construct of health numeracy. Using focus groups, we asked patients receiving hemodialysis open-ended questions to identify facilitators and barriers to their understanding, interpretation, and application of numeric information in kidney care. Transcripts were analyzed using content analysis. Twelve patients participated with a mean (standard deviation) age of 56 (12) years. All were African American, 50% were women, and 83% had an annual income <$20,000/year. Although patients felt numbers were critical to every aspect in life, they noted several barriers to understanding, interpreting and applying quantitative information specifically to manage their health. Low patient self-efficacy related to health numeracy and limited patient-provider communication about quantitatively based feedback, were emphasized as key barriers. Through focus groups of key patient stakeholders we identified important modifiable barriers to effective kidney care. Additional research is needed to develop tools that support numeracy-sensitive education and communication interventions in dialysis.

Predicting biases in very highly educated samples: Numeracy and metacognition

We investigated the relations between numeracy and superior judgment and decision making in two large community outreach studies in Holland (n=5408). In these very highly educated samples (e.g., 30–50% held graduate degrees), the Berlin Numeracy Test was a robust predictor of financial, medical, and metacognitive task performance (i.e., lotteries, intertemporal choice, denominator neglect, and confidence judgments), independent of education, gender, age, and another numeracy assessment. Metacognitive processes partially mediated the link between numeracy and superior performance. More numerate participants performed better because they deliberated more during decision making and more accurately evaluated their judgments (e.g., less overconfidence). Results suggest that well-designed numeracy tests tend to be robust predictors of superior judgment and decision making because they simultaneously assess (1) mathematical competency and (2) metacognitive and self-regulated learning skills.