Improving risk communication: a proof-of-concept randomised control trial assessing the impact of visual aids for neurosurgical consent

Introduction

Informed consent is a fundamental component in the work-up for surgical procedures. Statistical risk information pertaining to a procedure is by nature probabilistic and challenging to communicate, especially to those with poor numerical literacy. Visual aids and audio/video tools have previously been shown to improve patients' understanding of statistical information. In this study, we aimed to explore the impact of different methods of risk communication in healthy participants randomized to either undergo the consent process with visual aids or the standard consent process for lumbar puncture.

Material and methods

Healthy individuals above 18 years old were eligible. The exclusion criteria were prior experience of the procedure or relevant medical knowledge, lack of capacity to consent, underlying cognitive impairment and hospitalised individuals. After randomisation, both groups received identical medical information about the procedure of a lumbar puncture in a hypothetical clinical scenario via different means of consent. The control group underwent the standard consent process in current clinical practice (Consent Form 1 without any illustrative examples), whereas the intervention group received additional anatomy diagrams, the Paling Palette and the Paling perspective scale. Anonymised questionnaires were received to evaluate their perception of the procedure and its associated risks.

Results

Fifty-two individuals were eligible without statistically significant differences in age, sex, professional status and the familiarity of the procedure. Visual aids were noted to improve the confidence of participants to describe the risks by themselves (p = 0.009) and participants in the intervention group felt significantly less overwhelmed with medical information (p = 0.028). The enhanced consent process was found to be significantly more acceptable by participants (p = 0.03). There was a trend towards greater appropriateness (p = 0.06) and it appeared to have "good" usability (median SUS = 76.4), although this also did not reach statistical significance (p = 0.06).

Conclusion

Visual aids could be an appropriate alternative method for medical consent without being inferior regarding the understanding of the procedure, its risks and its benefits. Future studies could possibly compare or incorporate multiple interventions to determine the most effective tools in a larger scale of population including patients as well as healthy individuals.

Taxonomies for synthesizing the evidence on communicating numbers in health: Goals, format, and structure

Many people, especially those with low numeracy, are known to have difficulty interpreting and applying quantitative information to health decisions. These difficulties have resulted in a rich body of research about better ways to communicate numbers. Synthesizing this body of research into evidence-based guidance, however, is complicated by inconsistencies in research terminology and researcher goals. In this article, we introduce three taxonomies intended to systematize terminology in the literature, derived from an ongoing systematic literature review. The first taxonomy provides a systematic nomenclature for the outcome measures assessed in the studies, including perceptions, decisions, and actions. The second taxonomy is a nomenclature for the data formats assessed, including numbers (and different formats for numbers) and graphics. The third taxonomy describes the quantitative concepts being conveyed, from the simplest (a single value at a single point in time) to more complex ones (including a risk-benefit trade-off and a trend over time). Finally, we demonstrate how these three taxonomies can be used to resolve ambiguities and apparent contradictions in the literature.

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.

Association of Health Literacy and Numeracy With Lupus Knowledge and the Creation of the Lupus Knowledge Assessment Test

OBJECTIVE

Limited health literacy and numeracy are associated with worse patient-reported outcomes and higher disease activity in systemic lupus erythematosus (SLE), but which factors may mediate this association is unknown. We sought to determine the association of health literacy and numeracy with SLE knowledge.

METHODS

Patients with SLE were recruited from an academic center clinic. Participants completed validated assessments of health literacy (Newest Vital Sign [NVS]; n = 96) and numeracy (Numeracy Understanding in Medicine Instrument, Short Version [S-NUMI]; n = 85). They also completed the Lupus Knowledge Assessment Test (LKAT), which consists of 4 questions assessing SLE knowledge that were determined through consensus expert opinion for their wide applicability and importance related to self-management of the disease. Descriptive statistics and multivariable logistic regression modeling were used to analyze the results.

RESULTS

In our SLE cohort (n = 125), 33% (32/96) had limited health literacy and 76% (65/85) had limited numeracy. The majority correctly identified that hydroxychloroquine prevented SLE flares (91%); however, only 23% of participants correctly answered a numeracy question assessing which urine protein to creatinine (UPC) ratio was > 1000 mg/g. The mean LKAT score was 2.7 out of 4.0. Limited health literacy, but not numeracy, was associated with lower knowledge about SLE as measured by the LKAT, even after adjusting for education.

CONCLUSION

Patients with SLE with limited health literacy had lower knowledge about SLE. The LKAT could be further refined and/or used as a screening tool to identify patients with knowledge gaps. Further work is needed to improve patients' understanding of proteinuria and investigate whether literacy-sensitive education can improve care.

Numeracy and COVID-19: examining interrelationships between numeracy, health numeracy and behaviour

During the COVID-19 pandemic, people across the globe have been exposed to large amounts of statistical data. Previous studies have shown that individuals' mathematical understanding of health-related information affects their attitudes and behaviours. Here, we investigate the relation between (i) basic numeracy, (ii) COVID-19 health numeracy, and (iii) COVID-19 health-related attitudes and behaviours. An online survey measuring these three variables was distributed in Canada, the United States (US) and the United Kingdom (UK) (n = 2032). In line with predictions, basic numeracy was positively related to COVID-19 health numeracy. However, predictions, neither basic numeracy nor COVID-19 health numeracy was related to COVID-19 health-related attitudes and behaviours (e.g. follow experts' recommendations on social distancing, wearing masks etc.). Multi-group analysis was used to investigate mean differences and differences in the strength of the correlation across countries. Results indicate there were no between-country differences in the correlations between the main constructs but there were between-country differences in latent means. Overall, results suggest that while basic numeracy is related to one's understanding of data about COVID-19, better numeracy alone is not enough to influence a population's health-related attitudes about disease severity and to increase the likelihood of following public health advice.

Imprecision and Preferences in Interpretation of Verbal Probabilities in Health: a Systematic Review

INTRODUCTION

Many health providers and communicators who are concerned that patients will not understand numbers instead use verbal probabilities (e.g., terms such as "rare" or "common") to convey the gist of a health message.

OBJECTIVE

To assess patient interpretation of and preferences for verbal probability information in health contexts.

METHODS

We conducted a systematic review of literature published through September 2020. Original studies conducted in English with samples representative of lay populations were included if they assessed health-related information and elicited either (a) numerical estimates of verbal probability terms or (b) preferences for verbal vs. quantitative risk information.

RESULTS

We identified 33 original studies that referenced 145 verbal probability terms, 45 of which were included in at least two studies and 19 in three or more. Numerical interpretations of each verbal term were extremely variable. For example, average interpretations of the term "rare" ranged from 7 to 21%, and for "common," the range was 34 to 71%. In a subset of 9 studies, lay estimates of verbal probability terms were far higher than the standard interpretations established by the European Commission for drug labels. In 10 of 12 samples where preferences were elicited, most participants preferred numerical information, alone or in combination with verbal labels.

CONCLUSION

Numerical interpretation of verbal probabilities is extremely variable and does not correspond well to the numerical probabilities established by expert panels. Most patients appear to prefer quantitative risk information, alone or in combination with verbal labels. Health professionals should be aware that avoiding numeric information to describe risks may not match patient preferences, and that patients interpret verbal risk terms in a highly variable way.

Understanding of Numerical Information during the COVID-19 Pandemic

Media news during the Coronavirus Disease 2019 (COVID-19) pandemic often entail complex numerical concepts such as exponential increase or reproduction number. This study investigated whether people have difficulties in understanding such information and whether these difficulties are related to numerical competence, reflective thinking, and risk proneness. One hundred sixty-three participants provided answers to a numeracy scale focusing on complex numerical concepts relevant to COVID-19 (COV Numeracy Scale). They also provided responses to well-established objective and subjective scales, questions about affective states, and questions about the COVID-19 pandemic. Higher scores on the COV Numeracy Scale correlated with higher scores on the Health Numeracy Scale, in the Cognitive Reflection Test (CRT), and in self-assessments of verbal comprehension, mathematical intelligence, and subjective numeracy. Interestingly, scores on the COV Numeracy Scale also positively correlated with the number of consulted information sources about COVID-19. Accuracy in the CRT emerged as a significant predictor, explaining ca. 14% of variance on the COV Numeracy Scale. The results suggest that people with lower reflective thinking skills and lower subjective and objective numerical competence can be more at disadvantage when confronted with COVID-related numerical information in everyday life. These findings advise caution in the communication of relevant public health information that entails complex numerical concepts.

Using an educational intervention to assess and improve disease-specific knowledge and health literacy and numeracy in adolescents and young adults with haemophilia A and B

INTRODUCTION

Health literacy (HL) and health numeracy (HN) are underestimated barriers to treatment adherence in patients with haemophilia.

AIM

To test the ability of an educational intervention to improve knowledge, HL, HN, adherence and joint health in adolescent and young adult (AYA) males with haemophilia.

METHODS

We performed a longitudinal pilot study of 41 participants aged 12-21 years with haemophilia A or B during two clinic visits 6-12 months apart. The first visit included a comprehensive pre-intervention assessment: demographics, knowledge survey, Montreal Cognitive Assessment testing, 5-question tool to assess baseline HN, assessment of HL with the Rapid Estimate of Adolescent Literacy in Medicine tool, history of adherence and Haemophilia Joint Health Score (HJHS). An educational intervention using a visual aid explained basic pharmacokinetic (PK) concepts and personal teaching regarding haemophilia treatment regimens was used during this visit. The second visit included a post-intervention assessment: a reassessment of knowledge, HL, HN, HJHS, adherence to prescribed therapy and number of joint bleeds since the pre-intervention visit.

RESULTS

Forty-one males with haemophilia A or B were enrolled in the study. Of these, 33 completed the post-intervention assessment. Knowledge (p = .002) and HN (p = .05) were significantly improved post-intervention, although the HL, number of joint bleeds, adherence to prescribed therapy and HJHS were not.

CONCLUSIONS

Participants with low HL and/or HN may benefit from alternate methods of education such as audiovisual material. Education using audiovisual materials improved knowledge and HN in this study; however, this did not affect adherence to prescribed therapy.

Improving Communication in Breast Cancer Treatment Consultation: Use of a Computer Test of Health Numeracy

Background: Communication of statistics and probability is challenging in the cancer care setting. The objectives of this study are to evaluate a novel approach to cancer communication through the use of a computer assessment of patient health numeracy. Methods: We conducted a pilot study of the Computer Adapted Test of Numeracy Understanding in Medicine Instrument (CAT-NUMi) before the cancer treatment consultation for women with stage 0-3 breast cancer. Patient outcomes included the interpersonal processes of care (IPC) and the decisional conflict scale. We evaluated clinician use of numeric information in the cancer consultation and assessed feasibility outcomes from the clinician and patient perspective. Results: Patient participants (n = 50) had a median (interquartile range) age of 51 years (46-61), 70% were English speaking, and 30% Spanish speaking. Decisional conflict was low with a mean (standard deviation [SD]) decisional conflict score of 17.4 (12.3). The lack of clarity score (range 1-5) on the IPC was low (mean, SD),1.70 (0.71), indicating clear communication. Clinicians more often used percentages in communicating prognosis among those with higher numeracy scores (median, range): high (2, 0-8), medium (1, 0-7), and low (0, 0-8); p = 0.04. The patient experience of taking the CAT-NUMi was rated as very good or excellent by 65%, fair by 33%, and poor by 2% of patients. Conclusion: Screening for health numeracy with a short computer-based test may be a feasible strategy to optimize clear communication in the cancer treatment consultation. Further studies are needed to evaluate this strategy across cancer treatment clinical settings and populations.

Health Coaching Has Differential Effects on Veterans with Limited Health Literacy and Numeracy: a Secondary Analysis of ACTIVATE

BACKGROUND

Health coaching is an effective behavior change strategy. Understanding if there is a differential impact of health coaching on patients with low health literacy has not been well investigated.

OBJECTIVE

To determine whether a telephone coaching intervention would result in similar improvements in enrollment in prevention programs and patient activation among Veterans with low versus high health literacy (specifically, reading literacy and numeracy).

DESIGN

Secondary analysis of a randomized controlled trial.

PARTICIPANTS

Four hundred seventeen Veterans with at least one modifiable risk factor: current smoker, BMI ≥ 30, or < 150 min of moderate physical activity weekly.

METHODS

A single-item assessment of health literacy and a subjective numeracy scale were assessed at baseline. A logistic regression and general linear longitudinal models were used to examine the differential impact of the intervention compared to control on enrollment in prevention programs and changes in patient activation measures (PAM) scores among patients with low versus high health literacy.

RESULTS

The coaching intervention resulted in higher enrollment in prevention programs and improvements in PAM scores compared to usual care regardless of baseline health literacy. The coaching intervention had a greater effect on the probability of enrollment in prevention programs for patients with low numeracy (intervention vs control difference of 0.31, 95% CI 0.18, 0.45) as compared to those with high numeracy (0.13, 95% CI - 0.01, 0.27); the low compared to high differential effect was clinically, but not statistically significant (0.18, 95% CI - 0.01, 0.38; p = 0.07). Among patients with high numeracy, the intervention group had greater increases in PAM as compared to the control group at 6 months (mean difference in improvement 4.8; 95% CI 1.7, 7.9; p = 0.003). This led to a clinically and statistically significant differential intervention effect for low vs high numeracy (- 4.6; 95% CI - 9.1, - 0.15; p = 0.04).

CONCLUSIONS

We suggest that health coaching may be particularly beneficial in behavior change strategies in populations with low numeracy when interpretation of health risk information is part of the intervention. CLINICALTRIALS.

GOV IDENTIFIER

NCT01828567.

Association of Health Literacy and Numeracy with Interest in Research Participation

BACKGROUND

There is much attention to recruitment of diverse populations in research, but little is known about the influence of health literacy and numeracy skills.

OBJECTIVE

To determine if health literacy and numeracy affect individuals' interest to participate in research studies.

DESIGN

Cross-sectional survey data were pooled from 3 large studies conducted in the Mid-South Clinical Data Research Network.

PARTICIPANTS

Adult patients enrolled in 1 of 3 Mid-South Clinical Data Research Network studies.

MAIN MEASURES

The survey domains included demographic items, the 3-item Brief Health Literacy Screen (range 3-15), and the 3-item Subjective Numeracy Scale (range 3-18). The outcome was a sum index measure of a 7-item instrument (range 7-21) assessing individuals' interest in participating in different types of research, including research that involves taking surveys, giving a blood sample, participating via phone or internet, taking an investigational medication, meeting at a local community center or school, including family, or staying overnight at a hospital.

KEY RESULTS

Respondents (N = 15,973) were predominately women (65.5%), White (81.4%), and middle aged (M = 52.8 years, SD = 16.5); 32.4% previously participated in research. Self-reported health literacy was relatively high (M = 13.5 out of 15, SD = 2.1), and subjective numeracy skills were somewhat lower (M = 14.3 out of 18, SD = 3.6). After adjustment for age, gender, race, income, education, and other characteristics, lower health literacy and numeracy skills were each independently associated with less interest in research participation (p < 0.001 for each). Prior research participation was associated with greater interest in future research participation (p < 0.001).

CONCLUSIONS

After adjustment for factors known to be predictive of interest, individuals with lower health literacy or numeracy scores were less interested in participating in research. Additional work is needed to elucidate reasons for this finding and to determine strategies to engage these populations.

Health Literacy Studies Conducted in Australia: A Scoping Review

Health literacy (HL) is an essential component of various literacies mentioned in the field of health and education, including cultural, technological, media and scientific literacies. It is important for motivating higher consumer engagement. We aimed to review previous studies of HL in Australia to inform future studies, extend current knowledge and further enhance HL. Using search strings, a systematic search of four databases (i.e., MEDLINE; Embase; CINAHL and Eric) was carried out. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) based search strategy led to identification of a total of N = 9696 records, that were further screened for inclusion in the review. The review findings were categorized into three major themes: (1) HL and health numeracy; (2) contrast of: knowledge deficiency, knowledge gained, problems of current health care system and (3) HL measurement methods and its domains. The findings from this scoping review show a dearth of measurement tools with sound psychometric properties for assessing HL. The findings also reveal low levels of HL in consumers which is in turn affecting health-related behaviors, utilization of health services and navigation of the health system. More recent developments have tried to integrate vital aspects, including introduction of applications to increase HL and exploring HL in Aboriginal communities.

Tailoring Educational and Behavioral Interventions to Level of Health Literacy: A Systematic Review

Background: The relative value of universal compared to contingent approaches to communication and behavioral interventions for persons of low health literacy remains unknown. Objective: To examine the effectiveness of interventions that are tailored to individual health literacy level compared to nontailored interventions on health-related outcomes. Design: Systematic review. Data Sources: PubMed and Embase databases. Eligibility Criteria: Studies were eligible if they were in English, used an experimental or observational design, included an intervention that was tailored based on the individual's level of education, health literacy or health numeracy, and had a comparator group in which the intervention was not tailored to individual characteristics. Review Methods: Databases were searched from inception to January 2016, and the retrieved reference lists hand searched. Abstracts that met PICOS criteria underwent dual review for data extraction to assess study details and study quality. A qualitative synthesis was conducted. Results: Of 2,323 unique citations, 458 underwent full review, and 9 met criteria for the systematic review. Five studies were positive and rated as good quality, 3 were negative with 2 of those of good quality, and 1 had mixed results (fair quality). Positive studies were conducted in the clinical domains of hypertension, diabetes, and depression with interventions including educational materials, disease management sessions, literacy training, and physician notification of limited health literacy among patients. Negative studies were conducted in the clinical domains of heart disease, glaucoma, and nutrition with interventions including medication reconciliation and educational materials. Conclusions: Tailoring communication and behavioral interventions to the individual level of health literacy may be an effective strategy to improve knowledge and indicators of disease control in selected clinical settings.

Development and Validation of the Spanish Numeracy Understanding in Medicine Instrument

BACKGROUND

The Spanish-speaking population in the U.S. is large and growing and is known to have lower health literacy than the English-speaking population. Less is known about the health numeracy of this population due to a lack of health numeracy measures in Spanish.

OBJECTIVE

we aimed to develop and validate a short and easy to use measure of health numeracy for Spanish-speaking adults: the Spanish Numeracy Understanding in Medicine Instrument (Spanish-NUMi).

DESIGN

Items were generated based on qualitative studies in English- and Spanish-speaking adults and translated into Spanish using a group translation and consensus process. Candidate items for the Spanish NUMi were selected from an eight-item validated English Short NUMi. Differential Item Functioning (DIF) was conducted to evaluate equivalence between English and Spanish items. Cronbach's alpha was computed as a measure of reliability and a Pearson's correlation was used to evaluate the association between test scores and the Spanish Test of Functional Health Literacy (S-TOFHLA) and education level.

PARTICIPANTS

Two-hundred and thirty-two Spanish-speaking Chicago residents were included in the study.

KEY RESULTS

The study population was diverse in age, gender, and level of education and 70 % reported Mexico as their country of origin. Two items of the English eight-item Short NUMi demonstrated DIF and were dropped. The resulting six-item test had a Cronbach's alpha of 0.72, a range of difficulty using classical test statistics (percent correct: 0.48 to 0.86), and adequate discrimination (item-total score correlation: 0.34-0.49). Scores were positively correlated with print literacy as measured by the S- TOFHLA (r = 0.67; p < 0.001) and varied as predicted across grade level; mean scores for up to eighth grade, ninth through twelfth grade, and some college experience or more, respectively, were 2.48 (SD ± 1.64), 4.15 (SD ± 1.45), and 4.82 (SD ± 0.37).

CONCLUSIONS

The Spanish NUMi is a reliable and valid measure of important numerical concepts used in communicating health information.

A Qualitative Study on Health Numeracy and Patient-Provider Communication of Laboratory Numbers in Older African Americans with HIV

Health numeracy plays a vital role in the successful management of HIV because much HIV-related health information is expressed in quantitative terms. The purpose of our study was to explore what older African Americans with HIV (N = 20) understood about their HIV laboratory numbers and to examine communication of the numbers between patients and providers during clinic visits. The following four themes emerged: (a) HIV laboratory numbers are important to understand health status; (b) the numbers can often be confusing; (c) mutual communication between patient and provider is essential to understand the numbers; and (d) when communicating numbers, use less detail. Implications for future interventions to address health numeracy deficits in this population are discussed.

Health numeracy: the importance of domain in assessing numeracy

BACKGROUND AND OBJECTIVE

Existing research concludes that measures of general numeracy can be used to predict individuals' ability to assess health risks. We posit that the domain in which questions are posed affects the ability to perform mathematical tasks, raising the possibility of a separate construct of "health numeracy" that is distinct from general numeracy. The objective was to determine whether older adults' ability to perform simple math depends on domain.

METHODS

Community-based participants completed 4 math questions posed in 3 different domains: a health domain, a financial domain, and a pure math domain. Participants were 962 individuals aged 55 and older, representative of the community-dwelling US population over age 54.

RESULTS

We found that respondents performed significantly worse when questions were posed in the health domain (54% correct) than in either the pure math domain (66% correct) or the financial domain (63% correct). Our experimental measure of numeracy consisted of only 4 questions, and it is possible that the apparent effect of domain is specific to the mathematical tasks that these questions require.

CONCLUSIONS

These results suggest that health numeracy is strongly related to general numeracy but that the 2 constructs may not be the same. Further research is needed into how different aspects of general numeracy and health numeracy translate into actual medical decisions.

The meaning of numbers in health: exploring health numeracy in a Mexican-American population

BACKGROUND

Health numeracy can be defined as the ability to use numeric information in the context of health. The interpretation and application of numbers in health may vary across cultural groups.

OBJECTIVE

To explore the construct of health numeracy among persons who identify as Mexican American.

DESIGN

Qualitative focus group study. Groups were stratified by preferred language and level of education. Audio-recordings were transcribed and Spanish groups (n = 3) translated to English. An analysis was conducted using principles of grounded theory.

PARTICIPANTS

A purposeful sample of participants from clinical and community sites in the Milwaukee and Chicago metropolitan areas.

MAIN MEASURES

A theoretical framework of health numeracy was developed based upon categories and major themes that emerged from the analysis.

KEY RESULTS

Six focus groups were conducted with 50 participants. Initial agreement in coding was 59-67% with 100% reached after reconciliation by the coding team. Three major themes emerged: 1) numeracy skills are applied to a broad range of communication and decision making tasks in health, 2) affective and cognitive responses to numeric information influence use of numbers in the health setting, and 3) there exists a strong desire to understand the meaning behind numbers used in health. The findings informed a theoretical framework of health numeracy.

CONCLUSIONS

Numbers are important across a range of skills and applications in health in a sample of an urban Mexican-American population. This study expands previous work that strives to understand the application of numeric skills to medical decision making and health behaviors.

A framework for health numeracy: how patients use quantitative skills in health care

Our objective of this study is to develop a conceptual framework for the construct of health numeracy based on patient perceptions, using a cross-sectional, qualitative design. Interested participants (n=59) meeting eligibility criteria (age 40-74, English speaking) were assigned to one of six focus groups stratified by gender and educational level (low, medium, high). Fifty-three percent were male, and 47% were female. Sixty-one percent were white non-Hispanic, and 39% were of minority race or ethnicity. Participants were randomly selected from three primary care sites associated with an academic medical center. Focus group discussions were held in May 2004 and focused on how numbers are used in the health care setting. Data were presented from clinical trials to further explore how quantitative information is used in health communication and decision making. Focus groups were audio and videotaped; verbatim transcripts were prepared and analyzed. A framework of health numeracy was developed to reflect the themes that emerged. Three broad conceptual domains for health numeracy were identified: primary numeric skills, applied health numeracy, and interpretive health numeracy. Across domains, results suggested that numeracy contains an emotional component, with both positive and negative affect reflected in patient numeracy statements. We conclude that health numeracy is a multifaceted construct that includes applied and interpretive components and is influenced by patient affect.