Abstract
Health literacy and health numeracy refer to the skills and competencies that patients use to obtain health information, understand it, and apply it. However, the informatics literature and the patient education literature show that patients’ ability to obtain, understand, and apply health information is strongly influenced by factors other than their individual skills. For example, with poorly designed medication instructions, only high-literacy patients can choose the correct dose, but with well-designed instructions, both high- and low-literacy patients can do so. Clearly, understanding is influenced by not only by patient skills but also by healthcare provider communication skills, the design and accessibility of information resources, and the policies and resources of the healthcare system itself. In this chapter, we describe a distributed cognition model of health literacy and numeracy and demonstrate how it suggests systems approaches for addressing the problem. From this perspective, a patient’s failure to understand health information is always attributable to at least two weaknesses in the system: e.g., limited literacy skills combined with poorly designed information resources. Interventions can then be targeted to strengthen weaknesses at multiple places in the system. Case examples illustrate ways in which this perspective has stimulated effective health informatics interventions to address health literacy and numeracy.
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Ad Hoc Committee on Health Literacy for the Council on Scientific Affairs AMA. Health literacy: report of the council on scientific affairs. JAMA. 1999;281(6):552–7.
Ancker JS, Kaufman DR. Rethinking health numeracy: a multidisciplinary literature review. J Am Med Inform Assoc. 2007;14(6):713–21.
Ancker JS, Senathirajah Y, Kukafka R, Starren JB. Design features of graphs in health risk communication: a systematic review. J Am Med Inform Assoc. 2006;13(6):608–18.
Ancker J, Weber E, Kukafka R. Effects of game-like interactive graphics on risk perceptions and decisions. Med Decis Making. 2011a;31(1):130–42.
Ancker J, Weber E, Kukafka R. Effect of arrangement of stick figures on estimates of proportion in risk graphics. Med Decis Making. 2011b;31(1):143–50.
Ancker JS, Barron Y, Rockoff M, Hauser D, Pichardo M, Szcerenczy A, et al. Use of an electronic patient portal among disadvantaged populations. J Gen Intern Med. 2011c;26(10):1117–23.
Ancker JS, Witteman HO, Provencher T, Hafeez B, Wei E. Tracking personal data in multiple chronic disease: patient actions and perceptions. In: AcademyHealth annual research conference, 2015.
Ancker JS, Nosal S, Hauser D, Way C, Calman N. Access policy and the digital divide in patient access to medical records. In press 2017. Health Policy and Technology.
Ancker JS, Mauer E, Hauser D, Calman N. Expanding access to high-quality plain-language patient education information through context-specific hyperlinks. Proc AMIA Ann Symp. 2017;2017:36–41.
Bailey SC, Wolf MS, Lopez A, Russell A, Chen AH, Schillinger D, et al. Expanding the Universal Medication Schedule: a patient-centred approach. BMJ Open. 2014;4(1):e003699.
Baker DW. The meaning and measure of health literacy. J Gen Intern Med. 2006;21:878–83.
Baker D, Williams M, Parker R, Gazmararian J, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38(1):33–42.
Baker D, Gazmararian J, Williams M, Scott T, Parker R, Green D, et al. Functional health literacy and the risk of hospital admission among Medicare managed care enrollees. Am J Public Health. 2002;92(8):1278–83.
Bennett CL, Ferreira MR, Davis TC, Kaplan J, Weinberger M, Kuzel T, et al. Relation between literacy, race, and stage of presentation among low-income patients with prostate cancer. J Clin Oncol. 1998;16(9):3101–4.
Berkman M, Sheridan S, Donahue K, Halpern D, Viera A, Crotty K, et al. Health literacy interventions and outcomes: an updated systematic review. Rockville, MD: Agency for Healthcare Research and Quality; 2011. Contract No.: AHRQ Publication Number 11-E006.
Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36(8):588–94.
Cokely E, Galesic M, Schulz E, Ghazal S, Garcia-Retamero R. Measuring risk literacy: the Berlin numeracy test. Judgm Decis Mak. 2012;7(1):25–47.
Davis T, Long S, Jackson R, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25:391–5.
Davis TC, Federman AD, Bass PF, Jackson RH, Middlebrooks M, Parker RM, et al. Improving patient understanding of prescription drug label instructions. J Gen Intern Med. 2009;24(1):57–62.
DeWalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med. 2004;19:1228–39.
DeWalt DA, Broucksou KA, Hawk V, Brach C, Hink A, Rudd R, et al. Developing and testing the health literacy universal precautions toolkit. Nurs Outlook. 2011;59(2):85–94.
Dinh HT, Bonner A, Clark R, Ramsbotham J, Hines S. The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: a systematic review. JBI Database System Rev Implement Rep. 2016;14(1):210–47.
Edwards M, Wood F, Davies M, Edwards A. ‘Distributed health literacy’: longitudinal qualitative analysis of the roles of health literacy mediators and social networks of people living with a long-term health condition. Health Expect. 2015;18(5):1180–93.
Fagerlin A, Zikmund-Fisher B, Ubel P, Jankovic A, Derry H, Smith D. Measuring numeracy without a math test: development of the subjective numeracy scale. Med Decis Making. 2007;27(5):672–80.
Galesic M, Garcia-Retamero R. Do low-numeracy people avoid shared decision making? Health Psychol. 2011;30(3):336–41.
Golbeck AL, Ahlers-Schmidt CR, Paschal AM, Dismuke SE. A definition and operational framework for health numeracy. Am J Prev Med. 2005;29(4):375–6.
Gurmankin AD, Baron J, Armstrong K. The effect of numerical statements of risk on trust and comfort with hypothetical physician risk communication. Med Decis Making. 2004;24(3):265–71.
Hawley S, Zikmund-Fisher B, Ubel P, Jankovic A, Lucas T, Fagerlin A. The impact of the format of graphical presentation on health-related knowledge and treatment choices. Patient Educ Couns. 2008;73(3):448–55.
Institute of Medicine, Committee on Health Literacy. In: Nielsen-Bohlman L, Panzer AM, Kindig DA, editors. Health literacy: a prescription to end confusion. Washington, DC: The National Academies Press; 2004.
Kalichman SC, Ramachandran B, Catz S. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. J Gen Intern Med. 1999;14:267–73.
Kaplan RM. Shared medical decision making: a new tool for preventive medicine. Am J Prev Med. 2004;26(1):81–3.
Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. Adult literacy in America: a first look at the findings of the national adult literacy survey. Washington, DC: U.S. Department of Education Office of Educational Research and Improvement; 2002. NCES 1993-275.
Kornburger C, Gibson C, Sadowski S, Maletta K, Klingbeil C. Using “Teach-Back” to promote a safe transition from hospital to home: an evidence-based approach to improving the discharge process. J Pediatr Nurs. 2013;28(3):282–91.
Kutner M, Greenberg E, Jin Y, Paulsen C, White S. The health literacy of America’s adults: results from the 2003 national assessment of adult literacy. Washington, DC: National Center for Health Statistics; 2006. Contract No.: NCES 2006-483.
Leischow SJ, Milstein B. Systems thinking and modeling for public health practice. Am J Public Health. 2008;96(3):403–5.
Leischow SJ, Best A, Trochim WM, Clark PI, Gallagher RS, Marcus SE, et al. Systems thinking to improve the public’s health. Am J Prev Med. 2008;35(2S):S203.
Leventhal H, Leventhal EA, Breland JY. Cognitive science speaks to the “common-sense” of chronic illness management. Ann Behav Med. 2011;41(2):152–63.
Lipkus I, Samsa G, Rimer B. General performance on a numeracy scale among highly educated samples. Med Decis Making. 2001;21(1):37–44.
Mabry PL, Olster DH, Morgan GD, Abrams DB. Interdisciplinary and systems science to improve population health: a view from the NIH Office of Behavioral and Social Sciences Research. Am J Prev Med. 2008;35(2S):S211–S24.
McCray AT. Promoting health literacy. J Am Med Inform Assoc. 2005;12:152–63.
Meyer D, Leventhal H, Gutmann M. Common-sense models of illness: the example of hypertension. Health Psychol. 1985;4(2):115–35.
Morris NS, MacLean CD, Chew LD, Littenberg B. The single item literacy screener: evaluation of a brief instrument to identify limited reading ability. BMC Fam Pract. 2006;7:21.
Murphy P, David T, Long S, Jackson R, Decker B. Rapid estimate of adult literacy in medicine (REALM): a quick reading test for patients. J Read. 1993;37(2):124–30.
Nurss J, Parker R, Williams M, Baker D. TOFHLA test of functional health literacy in adults. Show Camp: Peppercorn Books and Press; 2001.
O’Connor A, Stacey D, Entwistle V, Llewellyn-Thomas H, Rovner D, Holmes-Rovner M, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev. 2007;2:CD001431.
Paasche-Orlow MK, Wolf MS. The causal pathways linking health literacy to health outcomes. Am J Health Behav. 2007;31(S1):S19–26.
Patel VL, Arocha JF, Kaufman DR. A primer on aspects of cognition for medical informatics. J Am Med Inform Assoc. 2001;8(4):324–43.
Patel VL, Branch T, Arocha JF. Errors in interpreting quantities as procedures: the case of pharmaceutical labels. Int J Med Inform. 2002;65:193–211.
Perry M. Distributed cognition. In: Carroll JM, editor. HCI models, theories, and frameworks: toward an interdisciplinary science. San Francisco: Morgan Kaufmann; 2003. p. 193–223.
Peters E, Vastfjall D, Slovic P, Mertz CK, Mazzocco K, Dickert S. Numeracy and decision making. Psychol Sci. 2006;17(5):407–13.
Rampey BD, Finnegan R, Goodman M, Mohadjer L, Krenzke T, Hogan J, et al. Skills of US unemployed, young, and older adults in sharper focus: results from the program for the international assessment of adult competencies (PIAAC) 2012/2014. Washington, DC: National Center for Education Statistics, US Department of Education; 2016. Contract No.: NCES 2016-039.
Ratzan SC, Parker RM. Health literacy. In: Selden CR, Zorn M, Ratzan SC, Parker RM, editors. National library of medicine current bibliographies in medicine. Bethesda: National Institutes of Health, US Department of Health and Human Services; 2000.
Reyna VF. A theory of medical decision-making and health: Fuzzy trace theory. Med Decis Making. 2008;28:850–65.
Reyna VF, Nelson WL, Han P, Dieckmann N. How numeracy influences risk comprehension and medical decision-making. Psychol Bull. 2009;135(6):943–73.
Rudd RE. Improving Americans’ health literacy. N Engl J Med. 2010;363(24):2283–5.
Schapira M, Walker C, Cappaert K, Ganschow P, Fletcher K, McGinley E, et al. The numeracy understanding in medicine instrument: a measure of health numeracy developed using item response theory. Med Decis Making. 2012;32(6):851–65.
Schapira M, Walker C, Miller T, Fletcher K, Ganschow P, Jacobs E, Imbert D, O’Connell M, Neuner J. Development and Validation of the Numeracy Understanding in Medicine Instrument Short Form. J Health Commun.19(2);240–53.
Schneider SJ, Gustavson B, Li T, Göksel H, DiGaetano R, Edwards WS. Personal health information management and the design of consumer health information technology: secondary analysis of data from the Medical Expenditure Panel Survey. Rockville: Agency for Healthcare Research and Quality; 2009. AHRQ Publication No. 09-0090-EF.
Schwartz L, Woloshin S, Black W, Welch H. The role of numeracy in understanding the benefit of screening mammography. Ann Intern Med. 1997;127(11):966–72.
Tait AR, Voepel-Lewis T, Zikmund-Fisher BJ, Fagerlin A. The effect of format on parents’ understanding of the risks and benefits of clinical research: a comparison between text, tables, and graphics. J Health Commun. 2010;15(5):487–501.
Trevena LJ, Zikmund-Fisher BJ, Edwards A, Gaissmaier W, Galesic M, Han PK, et al. Presenting quantitative information about decision outcomes: a risk communication primer for patient decision aid developers. BMC Med Inform Decis Mak. 2013;13(2):1–15.
Weiss BD, Mays ME, Martz W, Castro KM, DeWalt DA, Pignone MP, et al. Quick assessment of literacy in primary care: the newest vital sign. Ann Fam Med. 2005;3:514–22.
Weller J, Dieckmann N, Tusler M, Mertz C, Burns W, Peters E. Development and testing of an abbreviated numeracy scale: a Rasch Analysis approach. J Behav Decis Mak. 2013;26(2):198–212.
Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, et al. Inadequate functional health literacy among patients at two public hospitals. JAMA. 1995;274(21):1677–82.
Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functional health literacy to patients’ knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern Med. 1998;158(2):166–72.
Yin H, Mendelsohn AL, Wolf MS, et al. Parents’ medication administration errors: role of dosing instruments and health literacy. Arch Pediatr Adolesc Med. 2010a;164(2):181–6.
Yin H, Wolf M, Dreyer B, Sanders L, Parker R. Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications. JAMA. 2010b;304(23):2595–602.
Yin HS, Mendelsohn AL, Fierman A, van Schaick L, Bazan IS, Dreyer BP. Use of a pictographic diagram to decrease parent dosing errors with infant acetaminophen: a health literacy perspective. Acad Pediatr. 2011;11(1):50–7.
Yin HS, Dreyer BP, Moreira HA, van Schaick L, Rodriguez L, Boettger S, et al. Liquid medication dosing errors in children: role of provider counseling strategies. Acad Pediatr. 2014;14(3):262–70.
Zikmund-Fisher B, Smith D, Ubel P, Fagerlin A. Validation of the Subjective Numeracy Scale (SNS): effects of low numeracy on comprehension of risk communications and utility elicitations. Med Decis Making. 2007a;27(5):663–71.
Zikmund-Fisher B, Fagerlin A, Ubel P. Mortality versus survival graphs: improving temporal consistency in perception of treatment effectiveness. Patient Educ Couns. 2007b;66(1):100–7.
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Ancker, J.S. (2017). Addressing Health Literacy and Numeracy Through Systems Approaches. In: Patel, V., Arocha, J., Ancker, J. (eds) Cognitive Informatics in Health and Biomedicine. Health Informatics. Springer, Cham. https://doi.org/10.1007/978-3-319-51732-2_11
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