Examining the Interrelations Among Objective and Subjective Health Literacy and Numeracy and Their Associations with Health Knowledge

Breast cancer treatment receipt and the role of financial stress, health literacy, and numeracy among diverse breast cancer survivors

PURPOSE

Disparities in breast cancer treatment for low-income and minority women are well documented. We examined economic hardship, health literacy, and numeracy and whether these factors were associated with differences in receipt of recommended treatment among breast cancer survivors.

METHODS

During 2018-2020, we surveyed adult women diagnosed with stage I-III breast cancer between 2013 and 2017 and received care at three centers in Boston and New York. We inquired about treatment receipt and treatment decision-making. We used Chi-squared and Fisher's exact tests to examine associations between financial strain, health literacy, numeracy (using validated measures), and treatment receipt by race and ethnicity.

RESULTS

The 296 participants studied were 60.1% Non-Hispanic (NH) White, 25.0% NH Black, and 14.9% Hispanic; NH Black and Hispanic women had lower health literacy and numeracy and reported more financial concerns. Overall, 21 (7.1%) women declined at least one component of recommended therapy, without differences by race and ethnicity. Those not initiating recommended treatment(s) reported more worry about paying large medical bills (52.4% vs. 27.1%), worse household finances since diagnosis (42.9% vs. 22.2%), and more uninsurance before diagnosis (9.5% vs. 1.5%); all P < .05. No differences in treatment receipt by health literacy or numeracy were observed.

CONCLUSION

In this diverse population of breast cancer survivors, rates of treatment initiation were high. Worry about paying medical bills and financial strain were frequent, especially among non-White participants. Although we observed associations of financial strain with treatment initiation, because few women declined treatments, understanding the scope of impact is limited. Our results highlight the importance of assessments of resource needs and allocation of support for breast cancer survivors. Novelty of this work includes the granular measures of financial strain and inclusion of health literacy and numeracy.

Comparison of Newest Vital Sign and Brief Health Literacy Screen scores in a large, urban Hispanic cohort

OBJECTIVE

Prior studies comparing subjective and objective health literacy measures have yielded inconsistent results. Our aim was to examine the concordance between Newest Vital Sign (NVS) and Brief Health Literacy Screen (BHLS) scores in a large cohort of English- and Spanish-speaking urban Hispanic adults.

METHODS

Item means, standard deviations, corrected-item total correlations, Cronbach's alpha, and Spearman correlations and area under receiver operating characteristic (AUROC) curve analysis were used to compare NVS and BHLS items and total scores.

RESULTS

N = 2988 (n = 1259 English; n = 1729 Spanish). Scores on both measures demonstrated good internal consistency (NVS: α = .843 English, .846 Spanish; BHLS: α = .797 English, .846 Spanish) but NVS items had high difficulty; more than half of respondents scored 0. Measures were only weakly correlated (rs = .21, p < .001, English; rs = .19, p < .001, Spanish). The AUROC curves were .606 (English) and .605 (Spanish) for discriminating the lowest NVS scoring category.

CONCLUSION

Subjective health literacy scores were poor predictors of objective scores. Objective scores demonstrated floor effects, precluding discrimination at low levels of the trait continuum.

PRACTICE IMPLICATIONS

Subjective health literacy scores may fail to identify individuals with limited health literacy.

Beyond High-Income Countries: Low Numeracy Is Associated with Older Adult Age around the World

Background

Numeracy, or the ability to understand and use numbers, has been associated with obtaining better health and financial outcomes. Studies in high-income countries suggest that low numeracy is associated with older age-perhaps especially among individuals with lower education. Here, we examined whether findings generalize to the rest of the world.

Methods

Gallup surveyed >150,000 participants for the 2019 Lloyd's Register Foundation World Risk Poll, from 21 low-income, 34 lower-middle income, 42 upper-middle income, and 43 high-income countries. Low numeracy was operationalized as failing to correctly answer, "Is 10% bigger than 1 out of 10, smaller than 1 out of 10, or the same as 1 out of 10?"

Results

Regressions controlling for participants' education, income, and other characteristics found that, worldwide, low numeracy was associated with older age, lower education, and their interaction. Findings held in each country-income category, although low numeracy was more common in low-income countries than in high-income countries.

Limitations

Age differences may reflect cohort effects and life span-developmental changes.

Discussion

Low numeracy is more common among people who are older and less educated. We discuss the need for education and interventions outside of the classroom.

Highlights

We analyzed a global survey conducted in 21 low-income, 34 lower-middle income, 42 upper-middle income, and 43 high-income countries.Low numeracy was associated with older adult age, even after accounting for age differences in education.Low numeracy was more common in older people with lower education.

Leveraging Math Cognition to Combat Health Innumeracy

Rational numbers (i.e., fractions, percentages, decimals, and whole-number frequencies) are notoriously difficult mathematical constructs. Yet correctly interpreting rational numbers is imperative for understanding health statistics, such as gauging the likelihood of side effects from a medication. Several pernicious biases affect health decision-making involving rational numbers. In our novel developmental framework, the natural-number bias-a tendency to misapply knowledge about natural numbers to all numbers-is the mechanism underlying other biases that shape health decision-making. Natural-number bias occurs when people automatically process natural-number magnitudes and disregard ratio magnitudes. Math-cognition researchers have identified individual differences and environmental factors underlying natural-number bias and devised ways to teach people how to avoid these biases. Although effective interventions from other areas of research can help adults evaluate numerical health information, they circumvent the core issue: people's penchant to automatically process natural-number magnitudes and disregard ratio magnitudes. We describe the origins of natural-number bias and how researchers may harness the bias to improve rational-number understanding and ameliorate innumeracy in real-world contexts, including health. We recommend modifications to formal math education to help children learn the connections among natural and rational numbers. We also call on researchers to consider individual differences people bring to health decision-making contexts and how measures from math cognition might identify those who would benefit most from support when interpreting health statistics. Investigating innumeracy with an interdisciplinary lens could advance understanding of innumeracy in theoretically meaningful and practical ways.

Changes in the health literacy of residents aged 15-69 years in central China: A three-round cross-sectional study

Introduction

Health literacy is an effective strategy to promote more cost-effective use of health care services and a crucial tool for preventing the spread of infectious diseases. The main objective of this study was to analyze changes in health literacy from 2019 to 2021.

Methods

Data were from the latest three-round cross-sectional studies with the same study design.

Results

Although the prevalence of adequate health literacy rose significantly over time, increasing from 26.9% (95% CI 20.1-33.7) in 2019 to 34.1% (32.9-35.3) in 2021, it was still at a relatively low level. The most significant decrease was observed for health skills among the three aspects and health information literacy among the six dimensions. Working as medical staff was a protective factor for adequate health literacy, health skills literacy, and health information literacy. Risk factors for adequate health literacy and health information literacy were older age and lower education level. Furthermore, adequate health information literacy was positively related to annual family income.

Discussion

More practical and effective policies targeting health literacy for critical aspects and groups in Central China, are urgently needed, especially during the epidemic.

Improvement in Heart Failure Self-Care and Patient Readmissions with Caregiver Education: A Randomized Controlled Trial

Caregivers support heart failure (HF) self-care with little HF education. The purpose of this study was to evaluate the effectiveness of a caregiver-only educational intervention aimed at improving caregiver self-efficacy, perceived control, and HF knowledge, as well as patient self-care and 30-day cardiac readmission. In total, 37 patients and their caregivers were randomly assigned to a control condition or a caregiver-only educational intervention with telephone follow-up. Outcomes included patient 30-day cardiac readmission, patient self-care, caregiver self-efficacy, caregiver perceived control, and caregiver HF knowledge. Linear mixed model, Kaplan–Meier, and Cox regression analyses were used to determine the effects of the intervention on outcomes. Self-care maintenance ( p = 0.002), self-care management ( p = 0.005), 30-day cardiac readmission ( p = 0.003), and caregiver perceived control ( p < 0.001) were significantly better in the intervention group. The results suggest that interventions targeting caregiver HF education could be effective in improving HF patients’ 30-day cardiac readmissions, patient self-care, and caregiver perceived control.

Effect of linguistic framing and information provision on attitudes towards induced seismicity and seismicity regulation

Shale gas is an expanding energy source worldwide, yet ‘fracking’ remains controversial. Amongst public concerns is induced seismicity (tremors). The UK had the most stringent induced seismicity regulations in the world, prior to instating a moratorium on shale gas development. The Government cited induced seismicity as the key rationale for its November 2019 English moratorium. Yet, little is known about how the public perceives induced seismicity, whether they support regulatory change, or how framing and information provision affect perceptions. Across three waves of a longitudinal experimental UK survey (N = 2777; 1858; 1439), we tested whether framing of induced seismicity influences support for changing regulations. The surveys compared (1) quantitative versus qualitative framings, (2) information provision about regulatory limits in other countries and (3) seismicity from other industries, and (4) framing a seismic event as an ‘earthquake’ or something else. We find low support for changing current policy, and that framing and information provision made little difference to this. The one strong influence on perceptions of seismic events came from the type of activity causing the event; shale gas extraction clearly led to the most negative reactions. We discuss implications for future UK policy on shale gas and geothermal energy in an evolving energy landscape.

Confidence in COVID problem solving: What factors predict adults' item-level metacognitive judgments on health-related math problems before and after an educational intervention?

The advent of COVID-19 highlighted widespread misconceptions regarding people's accuracy in interpreting quantitative health information. How do people judge whether they accurately answered health-related math problems? Which individual differences predict these item-by-item metacognitive monitoring judgments? How does a brief intervention targeting math skills-which increased problem-solving accuracy-affect people's monitoring judgments? We investigated these pre-registered questions in a secondary analysis of data from a large Qualtrics panel of adults (N = 1,297). Pretest performance accuracy, math self-efficacy, gender, and math anxiety were associated with pretest item-level monitoring judgments. Participants randomly assigned to the intervention condition, relative to the control condition, made higher monitoring judgments post intervention. That is, these participants believed they were more accurate when answering problems. Regardless of experimental condition, those who actually were correct on health-related math problems made higher monitoring judgments than those who answered incorrectly. Finally, consistent with prior research, math anxiety explained additional variance in monitoring judgments beyond trait anxiety. Together, findings indicated the importance of considering both objective (e.g., problem accuracy) and subjective factors (e.g., math self-efficacy, math anxiety) to better understand adults' metacognitive monitoring.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11409-022-09300-3.

Health Literacy, Education, and Internal Consistency of Psychological Scales

Background:

Measurement error might lead to biased estimates, causing ineffective interventions and service delivery. Identifying measurement error of health-related instruments helps develop accurate assessment of health-related constructs.

Objective:

We compared the internal consistency of eight psychological scales used in health research in groups with adequate versus limited health literacy and in groups with higher versus lower education.

Methods:

Participants (N = 1,005) from a nationally representative internet panel completed eight self-report scales: (1) information avoidance, (2) cognitive causation, (3) unpredictability, (4) perceived severity, (5) time orientation, (6) internal health locus of control, (7) need for cognition, and (8) social desirability. The first four assess beliefs about diabetes and colon cancer. We used the Newest Vital Sign to categorize participants' health literacy (limited vs. adequate). We also categorized participants' education (high school or less vs. more than high school). We compared the Cronbach's alpha for each psychological scale between groups with different health literacy and education levels using the Feldt test.

Key Results:

Among all the 13 subscales, scale internal consistency was significantly lower among people with limited health literacy than those with adequate health literacy for five subscales: information avoidance for colon cancer (0.80 vs. 0.88), unpredictability of diabetes (0.84 vs. 0.88), perceived severity for diabetes (0.66 vs. 0.75), need for cognition (0.63 vs. 0.82), and social desirability (0.52 vs. 0.68). Internal consistency was significantly lower among people who had a high school education or less than among those with more than a high school education for four scales: perceived severity of diabetes (0.70 vs. 0.75), present orientation (0.60 vs. 0.66), need for cognition (0.73 vs. 0.80), and social desirability (0.61 vs. 0.70).

Conclusions:

Several psychological instruments demonstrated significantly lower internal consistency when used in a sample with limited health literacy or education. To advance health disparities research, we need to develop new scales with alternative conceptualizations of the constructs to produce a measure that is reliable among multiple populations. [HLRP: Health Literacy Research and Practice. 2021;5(3):e244–e255.]

Plain Language Summary:

We compared the internal consistency of several psychological scales in groups with adequate versus limited health literacy and higher versus lower education. For several scales, internal consistency was significantly lower among (1) people with limited health literacy compared those who have adequate health literacy and/or (2) people who had a high school education or less compared to those with more than a high school education.

Health Literacy and Outcomes Among Patients With Heart Failure: A Systematic Review and Meta-Analysis

OBJECTIVES

The purpose of this study was to determine if health literacy is associated with mortality, hospitalizations, or emergency department (ED) visits among patients living with heart failure (HF).

BACKGROUND

Growing evidence suggests an association between health literacy and health-related outcomes in patients with HF.

METHODS

We searched Embase, MEDLINE, PsycINFO, and EBSCO CINAHL from inception through January 1, 2019, with the help of a medical librarian. Eligible studies evaluated health literacy among patients with HF and assessed mortality, hospitalizations, and ED visits for all causes with no exclusion by time, geography, or language. Two reviewers independently selected studies, extracted data, and assessed the methodological quality of the identified studies.

RESULTS

We included 15 studies, 11 with an overall high methodological quality. Among the observational studies, an average of 24% of patients had inadequate or marginal health literacy. Inadequate health literacy was associated with higher unadjusted risk for mortality (risk ratio [RR]: 1.67; 95% confidence interval [CI]: 1.18 to 2.36), hospitalizations (RR: 1.19; 95% CI: 1.09 to 1.29), and ED visits (RR: 1.17; 95% CI: 1.03 to 1.32). When the adjusted measurements were combined, inadequate health literacy remained statistically associated with mortality (RR: 1.41; 95% CI: 1.06 to 1.88) and hospitalizations (RR: 1.12; 95% CI: 1.01 to 1.25). Among the 4 interventional studies, 2 effectively improved outcomes among patients with inadequate health literacy.

CONCLUSIONS

In this study, the estimated prevalence of inadequate health literacy was high, and inadequate health literacy was associated with increased risk of death and hospitalizations. These findings have important clinical and public health implications and warrant measurement of health literacy and deployment of interventions to improve outcomes.

Health Literacy in Pregnant Women: A Systematic Review

Health literacy plays a crucial role during pregnancy, as the mother’s health behavior influences both her own health and that of her child. To the authors’ best knowledge, no comprehensive overview on evidence of the health literacy of pregnant women and its impact on health outcomes during pregnancy exists. Therefore, this review aims to assess health literacy levels in pregnant women, whether health literacy is associated with outcomes during pregnancy and whether effective interventions exist to improve the health literacy of pregnant women. A systematic literature search was conducted in PubMed and EBSCO, resulting in 14 studies. The results show mixed levels of health literacy in pregnant women. Limited health literacy is associated with unhealthy behaviors during pregnancy. Mixed health literacy levels can be attributed to the recruitment site, the number of participants and the measurement tool used. Quality assessment reveals that the quality of the included studies is moderate to good. The review revealed that randomized controlled trials and interventions to improve health literacy in pregnant women are rare or do not exist. This is crucial in the light of the mixed health literacy levels found among pregnant women. Healthcare providers play a key role in this context, as pregnant women with limited health literacy rely on them as sources of health information.

Current Best Practice for Presenting Probabilities in Patient Decision Aids: Fundamental Principles

BACKGROUND

Shared decision making requires evidence to be conveyed to the patient in a way they can easily understand and compare. Patient decision aids facilitate this process. This article reviews the current evidence for how to present numerical probabilities within patient decision aids.

METHODS

Following the 2013 review method, we assembled a group of 9 international experts on risk communication across Australia, Germany, the Netherlands, the United Kingdom, and the United States. We expanded the topics covered in the first review to reflect emerging areas of research. Groups of 2 to 3 authors reviewed the relevant literature based on their expertise and wrote each section before review by the full authorship team.

RESULTS

Of 10 topics identified, we present 5 fundamental issues in this article. Although some topics resulted in clear guidance (presenting the chance an event will occur, addressing numerical skills), other topics (context/evaluative labels, conveying uncertainty, risk over time) continue to have evolving knowledge bases. We recommend presenting numbers over a set time period with a clear denominator, using consistent formats between outcomes and interventions to enable unbiased comparisons, and interpreting the numbers for the reader to meet the needs of varying numeracy.

DISCUSSION

Understanding how different numerical formats can bias risk perception will help decision aid developers communicate risks in a balanced, comprehensible manner and avoid accidental "nudging" toward a particular option. Decisions between probability formats need to consider the available evidence and user skills. The review may be useful for other areas of science communication in which unbiased presentation of probabilities is important.

Measuring health literacy combining performance-based and self-assessed measures: the roles of age, educational level and financial resources in predicting health literacy skills. A cross-sectional study conducted in Florence (Italy)

OBJECTIVE

The objective was to compare the results of performance-based and self-assessed measures of health literacy (HL) and to evaluate the contribution of their joint use in assessing some HL antecedents.

DESIGN

This was a cross-sectional study.

SETTING

The study was conducted on the general population in Florence (Italy).

PARTICIPANTS

This study is part of a larger one, where participants were randomly selected from the registries of 11 general practitioners working in the municipality of Florence. Inclusion criteria were the following: 18-69 years of age and Italian speaking. Exclusion criteria included cognitive impairment, severe psychiatric disease or end-stage disease. In this paper, 212 adults were included.

OUTCOME MEASURES

HL was measured using the European Health Literacy Survey Questionnaire (HLS-EU-Q16) and the Newest Vital Sign (NVS). The HL levels obtained by means of the two measurement tools were combined into a new variable that described three different levels of HL skills: low HL skills, partial HL skills and high HL skills. Multivariate ordinal logistic regression analysis was performed to assess the predictive roles of age class, educational level and financial resources with respect to HL skills.

RESULTS

Twenty-two per cent of the sample had high HL skills, 28.3% had low HL skills and 49.5% had partial HL skills. Educational level, age class and financial resources were significantly associated with HL skills, with OR values being higher than those obtained using the NVS or the HLS-EU-Q16 individually.

CONCLUSION

The combination of the results obtained using the NVS and the HLS-EU-Q16 improves the understanding of HL. The new variable generated by this combination could be considered as a different way to assess HL and its multidimensional contents.

How Do Subjective Health Literacy Measures Work in Young Adults? Specifying "Online" or "Paper-Based" Forms Impacts Results

Purpose. There is no gold-standard health literacy measure. The Single Item Literacy Screener (SILS) and Subjective Literacy Screener (SLS) ask people to self-report ability to understand health information. They were developed in older adults, before common use of electronic health information. This study explored whether the SILS and SLS related to objective literacy, numeracy, and comprehension among young adults, and whether specifying "online" or "paper-based" wording affected these relationships. Methods. Eligible individuals (18-35 years of age, English-speaking, US residents) from an online survey company were randomized to 1) original measures; 2) measures adding "paper-based" to describe health information/forms; or 3) measures adding "online" to describe health information/forms. We examined how each measure related to e-Health Literacy (eHEALS), subjective numeracy (SNS), objective numeracy (ONS), and comprehension of a short passage. Results. A total of 848/1342 respondents correctly answered attention-checks and were analyzed. The validated SILS related to comprehension (P = 0.003), eHEALS (P = 0.04), and ONS (P < 0.001) but not SNS (P = 0.44). When adding "paper-based," SILS related to eHEALS (P < 0.001) and ONS (P = 0.003) but did not relate to comprehension (P = 0.25) or SNS (P = 0.35). When adding "online," SILS related to comprehension (P < 0.001), eHEALS (P < 0.001), ONS (P = 0.005), and SNS (P = 0.03). The validated SLS related to comprehension (P < 0.001), eHEALS (P < 0.001), ONS (P < 0.001), and SNS (P < 0.001). When adding "paper-based," the SLS only related to eHEALS (P = <0.001) and comprehension (P = 0.03) but did not relate to ONS (P = 0.13) or SNS (P = 0.33). When adding "online," the SLS related to comprehension (P < 0.001), eHEALS (P < 0.001), and SNS (P = 0.03) but not ONS (P = 0.06). Conclusions. Young adults might interpret subjective health literacy measures differently when prompted to think about electronic or paper-based information. Researchers should consider clearer instructions or modified wording when using these measures in this population.

Using the Short Graph Literacy Scale to Predict Precursors of Health Behavior Change

BACKGROUND

Visual displays can facilitate risk communication and promote better health choices. Their effectiveness in improving risk comprehension is influenced by graph literacy. However, the construct of graph literacy is still insufficiently understood, partially because existing objective measures of graph literacy are either too difficult or too long.

OBJECTIVES

We constructed a new 4-item Short Graph Literacy (SGL) scale and examined how SGL scores relate to key cognitive, affective, and conative precursors of health behavior change described in common health behavior theories.

METHODS

We performed secondary analyses to adapt the SGL scale from an existing 13-item scale. The initial construction was based on data collected in a laboratory setting in Germany ( n = 51). The scale was then validated using data from nationally representative samples in Germany ( n = 495) and the United States ( n = 492). To examine how SGL scores relate to precursors of health behavior change, we performed secondary analyses of a third study involving a nationwide US sample with 47% participants belonging to racial/ethnic minorities and 46% with limited formal education ( n = 835).

RESULTS

Graph literacy was significantly associated with cognitive precursors in theoretically expected ways (e.g., positive associations with risk comprehension and response efficacy and a negative association with cognitive risk perception). Patterns for affective precursors generally mirrored those for cognitive precursors, although numeracy was a stronger predictor than graph literacy for some affective factors (e.g., feelings of risk). Graph literacy had predictive value for most cognitive and affective precursors beyond numeracy. In addition, graph literacy (but not numeracy) predicted key conative precursors such as defensive processing.

CONCLUSIONS

Our data suggest that the SGL scale is a fast and psychometrically valid method for measuring objective graph literacy. Our findings also highlight the theoretical and practical relevance of graph literacy.