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Health NumeracyStrategies for Increasing Comprehension
Brought to you by the Minnesota Health Literacy Partnership
Kate MurrayUniversity of Minnesota School of Public HealthIntern, Minnesota Health Literacy Partnership
Activity 1: Pop Quiz!
ObjectivesDefine health numeracy
Learn how health numeracy can affect patients and populations
Gain understanding of how patients process data
Learn strategies for using numbers (if at all!) in patient communication
Optional: Consider special cases involving numeracy, such as risk communication and data visualization
What is health numeracy?
“Mathematical literacy as it relates to health.”
“Numeracy is an aspect of health literacy that includes the quantitative skills necessary to understand and act on numerical directions given by health care providers.”
- Journal of Asthma, “Asthma Numeracy Skill and Health Literacy”
What is health numeracy?
“Health numeracy is the ability to access, interpret, and use quantitative information to manage one’s health.”
- Fairview Health Services
What is health numeracy?
Why health numeracy mattersLow numeracy is tied to:
Shorter life expectancyLower health outcomes overallHigher incidence of ER visitsHigher hospital recidivismPoor medication adherencePoor chronic disease managementHigher comorbidityHigher body mass index
Why health numeracy mattersDirect relation to health disparities
Emphasis on shared decision-making
More quantitative information than ever
The scope of the problem
• Over half of U.S. adults have only basic or below-basic number skills
• Math anxiety and health events further diminish numeracy ability
• Elderly, less-educated, non-English-speaking, and those of low socioeconomic status are at greater risk
How Patients Learn
How Patients Learn
Data: Friend or Foe?
Knowing when not to use numbers is just as important as knowing how to use them
Reduce the cognitive burden
Focus instead on outcomes and actions
How Patients Learn
The “Curse of Knowledge”
Once we know something, we find it hard to imagine what it was like not knowing it!
How Patients Learn
Fuzzy-Trace Theory
Verbatim thinking – precise details and facts. Quantitative.
Gist-based thinking – the bottom line. Relational, categorical, intuitive. Also subjective/based upon emotion, culture, education, experience, world view.
How Patients Learn
Focus on bridging information and action through gist-based messaging first.
If necessary, reinforce the message carefully with data.
How Patients Learn“Well Mr. Fischer, your systolic blood pressure is 150 and your diastolic is 95, indicating primary hypertension. You’ll cut your risk of heart disease by 50% if you can quit smoking. We could also get you on 25 milligrams of beta-blockers once a day. What do you think about that?”
How Patients Learn“Well Mr. Fischer, your systolic blood pressure is 150 and your diastolic is 95, indicating primary hypertension. You’ll cut your risk of heart disease by 50% if you can quit smoking. We could also get you on 25 milligrams of beta-blockers once a day. What do you think about that?”
“Mr. Fischer, your blood pressure is high. [pause] If you quit smoking, you can cut your risk of heart disease in half. [pause] There are also medications that can help.” [pause]
How Patients Learn“Well Mr. Fischer, your systolic blood pressure is 150 and your diastolic is 95, indicating primary hypertension. You’ll cut your risk of heart disease by 50% if you can quit smoking. We could also get you on 25 milligrams of beta-blockers once a day. What do you think about that?”
“Mr. Fischer, your blood pressure is high. [go to visual aid] If you quit smoking, you can cut your risk of heart disease in half. [action plan] There are also medications that can help.” [decision aid]
Activity 2: Practicing the gist
Using Numbers with Patients
Category Examples
Basic• Reading numbers• Counting• Telling time
Computational • Arithmetic operations
Analytical• Ranges• Frequencies & percentages• Reading basic tables & graphs
Statistical• Interpreting risk statements• Reading complex graphs• Comparing numbers on different scales
Using Numbers with Patients
• Increase knowledge• Instruct how to• Inform decision-making• Persuade/motivate
Using Numbers with Patients
Order
• Start with the most important information
• Put figures in logical order (such as by date or alphabetically)
• Consider using descending order when “big” equals “bad” or is the most important value
Using Numbers with Patients
• Unpack complex concepts
• One idea at a time
• Keep pieces logical,organized
• Underscore the gist of each piece
Less is More
Using Numbers with Patients
Rounding and Denominators• Round numbers are easier to understand,
compare, and recall
• Keep denominators consistent
Using Numbers with Patients
Instead of this… Use this…
78.64% 79%, or about 80%
1 in 10 vs. 1 in 5 1 in 10 vs. 2 in 10
Do the Math
• Do the computations for the patient
• Suggest online tools and calculators
• Mark medicine cups and syringes
• Use pill cards
Using Numbers with Patients
Visual Aids and Cues
• Can clarify, reinforce, reframe
• Helpful for visual learners
• Visual analogies
• Highlight the most relevant information
Using Numbers with Patients
Visual Aids and Cues
Use caution with graphs, charts, icon arrays, and
handouts!
Using Numbers with Patients
Narrative Support
• Context and reframing
• Links abstract to concrete
• Humanizes numbers
Using Numbers with Patients
Consider Cultural Differences
• U.S. Standard or metric
• Meanings and connotations
• Symbols
• Colors
Using Numbers with Patients
Plain Language
• Always advisable in health communication!
• Avoid technical and medical terminology
• Background information on a need-to-know basis
Using Numbers with Patients
plain
Teach-back & Open-ended Questions
• Have them teach it back in their own words
• What will they tell their spouse/partner/etc.?
• Emphasize that this testing your abilities, not theirs
• Avoid yes-or-no questions, especially, “Do you understand?”
Using Numbers with Patients
Activity 3: How should this information be presented?
Visualizing Health Information
Visualizing Health Information
True or False?Images like infographics are easier to understand than a paragraph of plain text because pictures don’t require literacy skills.
Visualizing Health Information
True or False?Images like infographics are easier to understand than a paragraph of plain text because pictures don’t require literacy skills.
F A L S E
Visualizing Health Information
Document literacy: the ability to search, comprehend, and use non-continuous texts
Reading a table requires:• Understanding rows and column headings• Selecting the right row + column of interest• Locating the cell at that intersection• Scanning up and down and back and forth
repeatedly
Visualizing Health Information
• One message per graph• Fewer categories• Downplay the noise• White space is your friend!• Avoid embellishments
Simplify
Visualizing Health Information
• Audience-appropriate• Order• Intuitive, consistent• Able to stand alone• Underscore the gist• Highlight or circle
Clarify
Visualizing Health Information
• Right-justify numbers
in tables• 10-14 point fonts • Simple, no-frills font• Clear and concise
labels and legends• Title (who, what,
when)
Text
Visualizing Health Information
• White or subdued
background• Adequate contrast• Printer-friendly• Color-blind safe• Action colors
Color
Visualizing Health Information
• Remember the “why”• Underscore the gist!• Use as a supplement
Choosing a Display Type
Visualizing Health Information
• Displays related parts of
a whole (proportions)• Good for highlighting
smallest/largest piece• Adds up to 100%• Variation: donut chart
Pie and Donut Charts
Visualizing Health Information
Do:• Point the largest slice
at 12 o’clock• Use short labels or a
legend• Slices in clockwise-
descending order
Don’t:• Show >6 slices
Pie and Donut Charts
Visualizing Health Information
• Show relative differences/patterns
• Vertical: emphasize rise and fall
• Horizontal: allows for longer labels; may be more intuitive
Bar Graphs
Visualizing Health Information
Do:• Use 6 or fewer bars• Select intervals, and
beginning/ending values carefully
Don’t:• Use overlays or
stacked bars
Bar Graphs
Visualizing Health Information
• Great for showing trends over time
• Effective for before and after differences
• Obvious rising, falling, and stasis of data
Line Graphs
Visualizing Health Information
Line GraphsDo:• Use indicators to highlight
key events• Use intervals and
beginning/ending values that make sense
Don’t:• Use >4 trend lines• Add too much text/data
Visualizing Health Information
• Great for probability data (absolute risk)
• Units can be counted, making them easier to understand
• Shows parts-to-whole relationship without percentages
• Can also use height cue
Icon Arrays (Pictographs)
Visualizing Health Information
Icon Arrays (Pictographs)
Visualizing Health Information
Do:• Consider using people-shaped icons to
humanize the data• Highlight the numerator• Place icons adjacently• Keep common denominators
between arrays
Icon Arrays (Pictographs)
Visualizing Health Information
Don’t:• Use too many
colors or symbols within one array
• Crowd with text or numbers
Icon Arrays (Pictographs)
Activity 4: Which Graphic Is Best?
Risk Communication
Risk Communication
• Eliminate all but the key information
• Round to whole numbers
• Start with the gist, then qualify with numbers
Risk Communication
• Use frequencies instead of percentages
• Keep denominators constant
• Use large denominators for small risks
Risk Communication
• Provide both positive and negative frames• Keep timeframes constant• Compare against a clear baseline
Risk Communication
Absolute or Relative Risk?
Relative risk: “This treatment will reduce your symptoms but it doubles the risk of cancer.”
Risk Communication
Absolute or Relative Risk?
Relative risk: “This treatment will reduce your symptoms but it doubles the risk of cancer.”
Absolute risk:“With this treatment, your risk of cancer will go from 1% to 2%.”
Risk Communication
• Dr. Brain J. Zikmund-Fisher
• Risk communication framework
• Possibility statements vs. Probability statements
• “The right tool at the right time”
Risk CommunicationIf your goal is to:Avoid surprise or regret for the patient
Decision example:Seeking informed consent for a treatment with rare complications
The patient will need a:Possibility statement (instead of probability/stats)
Narrative Example:“There is a small risk of hives with this medicine.”
Risk CommunicationIf your goal is to:Emphasize a better treatment option or rank a set of potential risks
Decision Example:Choosing between medications of the same class
The patient will need a:Relative possibility statement comparing options
Narrative Example:“This birth control pill is as effective as the older formula but has fewer side effects.”
Risk CommunicationIf your goal is to:Motivate the patient to act or not act
Decision Example:Categorical risk calculators
The patient will need a:Possibility statement (not probability/stats) involving categories or descriptors
Narrative Example:“Robert is at above-average risk for diabetes.”
Risk CommunicationIf your goal is to:Inform the patient of potentially high risks
Decision Example:Treatment options based on patient’s preferences
The patient will need a:Comparative possibility and/or probability statements
Narrative Example:“The surgery has higher risk of complications, with 35% of patients experiencing erectile dysfunction.”
Risk CommunicationIf your goal is to:Help the patient decide between treatments with varying risks of serious outcomes
Decision Example:Risk-reducing and secondary treatments
The patient will need a:Compare precise or incremental probabilities
Narrative Example:“If you follow this round of radiation with chemo, your risk of the cancer spreading will go from 20% to 12%.”
Risk Communication
• Patients may have all of these needs at different points in time
• It’s the communicator’s responsibility to adjust their strategy
• Consider what the patient wants to know
• Less is more!
Questions? Comments?
Additional ResourcesNIH Making Data Talk: A Workbook:Key concepts, practical suggestions, and examples on communicating health-related data to the public, policy makers, and the mediacancer.gov/publications/health-communication
Minnesota Health Literacy Partnership:Free resources to help educate individuals and health care professionals about the importance of health literacyhealthliteracymn.org
Additional ResourcesHealth Literacy Out Loud:Podcasts and articles about health literacy healthliteracyoutloud.com
Centers for Disease Control and Prevention:Toolkits and courses from the CDC and beyondwww.cdc.gov/healthliteracy/gettraining.html
Additional Resources
Federal plain language guidelines:plainlanguage.gov
UnitedHealth Group:Plain language glossaries in English and Spanishjustplainclear.com
Additional ResourcesUniversity of Michigan Risk Science Center:Explore and make your own data visualizations
iconarray.com
vizhealth.org
Tools for selecting color schemes for graphics:color-blindness.com (simulator)
colorbrewer2.org
AcknowledgementsMinnesota Health Literacy Partnershiphealthliteracymn.org
Minnesota Literacy Councilmnliteracy.org
Minnesota Hospital AssociationPatient and Family Advisory Councilmnhospitals.org
AcknowledgementsCommunity Health Initiative | U of Mdiversity.umn.edu/bced/chi
Made possible by a grant fromMedica
Very special thanks toAlisha Ellwood OdhiamboChairperson, MHLP
Thank you!
Brought to you by the Minnesota Health Literacy Partnership
Kate MurrayUniversity of Minnesota School of Public HealthIntern, Minnesota Health Literacy Partnership