Health Numeracy Strategies for Increasing Comprehension Brought to you by the Minnesota Health Literacy Partnership Kate Murray University of Minnesota

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”


“Health numeracy is the ability to access, interpret, and use quantitative information to manage one’s health.”

- Fairview Health Services


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?”


“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]


“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


• Increase knowledge• Instruct how to• Inform decision-making• Persuade/motivate


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


• Unpack complex concepts

• One idea at a time

• Keep pieces logical,organized

• Underscore the gist of each piece

Less is More


Rounding and Denominators• Round numbers are easier to understand,

compare, and recall

• Keep denominators consistent


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


Visual Aids and Cues

• Can clarify, reinforce, reframe

• Helpful for visual learners

• Visual analogies

• Highlight the most relevant information


Visual Aids and Cues

Use caution with graphs, charts, icon arrays, and

handouts!


Narrative Support

• Context and reframing

• Links abstract to concrete

• Humanizes numbers


Consider Cultural Differences

• U.S. Standard or metric

• Meanings and connotations

• Symbols

• Colors


Plain Language

• Always advisable in health communication!

• Avoid technical and medical terminology

• Background information on a need-to-know basis


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?”


Activity 3: How should this information be presented?

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.


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


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


• One message per graph• Fewer categories• Downplay the noise• White space is your friend!• Avoid embellishments

Simplify


• Audience-appropriate• Order• Intuitive, consistent• Able to stand alone• Underscore the gist• Highlight or circle

Clarify


• Right-justify numbers

in tables• 10-14 point fonts • Simple, no-frills font• Clear and concise

labels and legends• Title (who, what,

when)

Text


• White or subdued

background• Adequate contrast• Printer-friendly• Color-blind safe• Action colors

Color


• Remember the “why”• Underscore the gist!• Use as a supplement

Choosing a Display Type


• Displays related parts of

a whole (proportions)• Good for highlighting

smallest/largest piece• Adds up to 100%• Variation: donut chart

Pie and Donut Charts


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


• Show relative differences/patterns

• Vertical: emphasize rise and fall

• Horizontal: allows for longer labels; may be more intuitive

Bar Graphs


Do:• Use 6 or fewer bars• Select intervals, and

beginning/ending values carefully

Don’t:• Use overlays or

stacked bars

Bar Graphs


• Great for showing trends over time

• Effective for before and after differences

• Obvious rising, falling, and stasis of data

Line Graphs


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


• 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)




Do:• Consider using people-shaped icons to

humanize the data• Highlight the numerator• Place icons adjacently• Keep common denominators

between arrays



Don’t:• Use too many

colors or symbols within one array

• Crowd with text or numbers


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

http://www.cancer.gov/publications/health-communication

http://healthliteracymn.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

http://healthliteracyoutloud.com/

http://www.cdc.gov/healthliteracy/gettraining.html

http://www.cdc.gov/healthliteracy/gettraining.html

Additional Resources

Federal plain language guidelines:plainlanguage.gov

UnitedHealth Group:Plain language glossaries in English and Spanishjustplainclear.com

http://www.plainlanguage.gov/

http://www.justplainclear.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

http://www.iconarray.com/

http://www.vizhealth.org/

http://www.color-blindness.com/coblis-color-blindeness-simulator

http://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

Documents

Health Numeracy Strategies for Increasing Comprehension Brought to you by the Minnesota Health Literacy Partnership Kate Murray University of Minnesota