By Helen Osborne, M.Ed., OTR/L
President of Health Literacy Consulting

The diabetes pamphlet states, “Even a small decrease in weight can reduce the chance of getting diabetes.” At first glance, this sentence may seem simple for most readers to understand. But according to Elana Joram, PhD, an associate professor in the Department of Educational Psychology and Foundations at the University of Northern Iowa, this sentence presents a concept that is actually quite difficult to get. Joram says that this sentence has a high quantitative load despite the absence of numbers. Even though there are just a few, familiar words, readers still need to understand the quantitative terms embedded in the words “small,” “decrease,” “weight,” “reduce,” and “chance.”

Joram uses the term health numeracy when referring to the quantitative aspect of health information. She and colleagues state that “health numeracy occurs when individuals are able to access, process, interpret, communicate, and act on quantitative health information needed to be informed about health issues, perform routine health care actions, and make effective health decisions” (E Joram, et al. “Health Numeracy as Social Practice: A Conceptual Framework,” unpublished paper.).

Health numeracy includes a broad spectrum of quantitative concepts. Many of these are abstract, not concrete or visible. Risk and probability are examples of concepts that many people have trouble picturing and understanding. Nonetheless, quantitative information is prevalent throughout healthcare and needed for tasks such as measuring medication and calculating portion size.

Joram is learning more about health numeracy by coding the quantitative concepts found in 50 commonly-used diabetes materials. She not only is discovering challenges inherent in this information but also identifying solutions. She offers these suggestions to help healthcare providers more clearly communicate quantitative information.

Assume patients lack knowledge of quantitative concepts. Many people, even those who are highly educated and literate, can have trouble understanding numbers or have an aversion to using them. While numbers may be second-nature to scientists, the same is not necessarily true for patients or even all providers. Joram recommends not assessing which individuals have problems but rather communicating more simply with everyone. “You won’t go wrong if you explain clearly,” Joram says.

Focus on just one idea at a time. Joram found in her research that there often are many quantitative concepts packed into just one sentence. These can be complicated and conditional such as, “If your blood glucose is 70 mg/dl or below, have 2 to 5 glucose tablets, ½ cup (4 ounces) of fruit juice, or ½ cup of a regular soft drink to raise your blood glucose.”

Joram refers to this as “quantitative concept density” and says it is almost guaranteed to cause confusion. To communicate quantitative information more clearly, she recommends focusing on just one idea at a time and expressing it in simple sentences. For example, the above could be written more simply as “Check your blood glucose. If it is 70 or below, have a small carbohydrate snack such as a half-cup of fruit juice or regular soda. Or you can have 2 to 5 glucose tablets. This will make your blood glucose higher.”

Offer support for ideas. A principle of good classroom teaching is to offer students support for learning new ideas. Joram and her colleagues say that this technique is equally helpful when providers talk with patients about quantitative concepts. Here are some examples:

• Draw a picture showing what the thermometer looks like when a person’s temperature is too high.
• Use analogies or reference points to explain quantity. Joram says that dieticians often do this by comparing meat portions to a deck of cards or size of a person’s fist.
• Show physical representations of quantity. An example is a dinner plate sectioned-off into the correct amount of vegetables, protein, and carbohydrates.
• Encourage patients to create their own images. Joram talks of one man who says his image of a mile is four laps around the high school track.
• Use vivid language. Joram finds that newspaper journalists often present quantitative information in vivid and understandable ways such as writing that the stock market “inched up” or “went on a roller coaster ride.” Healthcare providers can do likewise by using colorful and descriptive language when talking about numbers.
• Teach with stories. When instructing patients about the need to walk 3 times a day for a total of 30 minutes, you might tell about a woman who takes short walks after breakfast, lunch, and dinner. For many people this narrative is easier to understand and remember than dividing 30 minutes by 3.

Use numbers when they are really needed. Even though numbers can be difficult to understand, sometimes they are needed for precision. Joram talks about instructions for an ultrasound test that asks patients to arrive with a full bladder. But the technicians report that sometimes patients do not understand what this means and the test must be delayed or rescheduled. Joram says that in situations like this, instructions could be more explicit such as stating, “Drink at least 4 cups of liquid an hour before your ultrasound test.”

Find out which measurement system your patient uses. In the U.S., most people are familiar with the Customary U.S. system of measurement. But people from other countries likely know the metric system instead. Find out which system your patient is familiar with and use that as a frame of reference. For instance, this can be talking about grams instead of ounces or teaspoons instead of mls. As with all health communication, Joram suggests using words, terms, and even numbers that your patients can understand.

Ways to learn more:

Elana Joram, PhD, is an associate professor in the Department of Educational Psychology & Foundations at the University of Northern Iowa. You can contact her by email at Elana.joram@uni.edu

• Davis TC, Wolf MS, BassPF, Thompson JA, Tilson HH, Neuberger M, and Parker RM (2006). Literacy and Misunderstanding of Prescription Drug Labels. Annals of Internal Medicine,. 145(12): 887-895.
• Peters, E., Hibbard, J., Slovic, P. Dieckmann, N. (2007). Numeracy skill and the communication, comprehension, and use of risk-benefit information. Health Affairs, 26(3): 741-8.

Helen Osborne, MEd, OTR/L, is president of Health Literacy Consulting. Her column appeared regularly in On Call. You can contact her by e-mail at Helen@healthliteracy.com.