In this paper we sought to explore how numeric information is used in health and the applicability of existing health frameworks among a study population that was self-identified as Mexican American. We chose to examine concepts among both Spanish and English-speaking persons in order to gain insights from a diverse sample in the community. Our study added several new insights into a framework of the use of numeracy skills in the context of health. First, our findings highlight numeracy skills that are applied in health across both Spanish and English language in the urban Mexican-American sample of this study. These skills are consistent with previous studies of health numeracy in general populations. Second, our study identified specific affective and cognitive responses to numeric information that could influence how numbers are understood and applied in the context of health. Finally, our work highlights the strong desire to better understand the meaning behind numbers and the relationship of numeric indicators to the underlying disease and treatment processes.
We found that some applications of numbers in health were broadly used. One such example is the use of scales to communicate symptoms or severity of disease. A basic attribute of numeric systems is that they represent an order of magnitude. Our data suggest that scales provide an intuitive way for people to think about severity of symptoms or disease. Although scales are widely recognized and used, cross-cultural research has demonstrated that probabilistic thinking and the response to a scale differs across cultures and ethnic backgrounds14–17
. Our study supports the importance of a discussion with the patient of the attributes of a scale (such as directionality) and the interpretation of various levels when it is used in the clinical setting.
Our study has identified both affective and cognitive responses to the use of numeric information in health. The role of affective response to numeric information is consistent with a growing body of literature that suggests there is an interaction between affect and the application of numbers in medical decision making4,18
and with previous findings that numeric presentations of risk information can increase trust of information presented19
Our study highlights the perceived importance of population specific risk and outcomes information if people are to find health statistics credible and applicable to their personal health. This finding is consistent with previous work that demonstrates the importance of an evidential approach to health communication, i.e., presenting evidence of impact specific to members of a target group19
. If patients are to believe in the applicability of health statistics, it is necessary for them not only to understand statistical information but to believe that it applies to people that are similar to themselves in ways perceived to be significant, including culture and ethnicity.
A salient theme to emerge from our study was the desire to better understand the meaning of numbers. Participants understood that doctors used numbers in decision making. However, they lacked understanding of the connection between the numeric indicator and their health condition. Patients desire a clearer connection between the numeric representation of a disease process or response to therapy and the physiologic process that is occurring. The drive to understand the meaning of numbers was also a component of the theoretical framework of health numeracy developed by Lipkus and Peters4
The theoretical framework of health numeracy presented is consistent with previous work conducted by our group and others in general populations with respect to the categories of numeric skills applied in the health context1–3
. A recent review outlines four theoretical approaches relevant to the study of health numeracy: psychophysical, computational, dual-process, and fuzzy trace theory6
. Our framework incorporates elements of dual-process theory in identifying the role of both cognitive and affective responses to the use of numbers in health. The framework presented is also similar to those developed by Lipkus and Peters in describing the process that one takes in applying numeracy skills to the health care context and using numeric based information to influence health care decisions and outcomes4,5
. Our framework is unique in that it is developed based on empiric data obtained from focus groups among Mexican-American community members. This work thus serves to broaden our understanding of the theoretical construct of health numeracy to reflect the experience of a minority population.
Our study has some limitations. The sample was primarily Mexican American but included one participant that was from South America. However, this participant lived and self-identified as being from a Mexican-American community. The study was not designed to directly compare frameworks of health numeracy across language, level of acculturation, or educational groups. However, the themes that emerged in our study reflect perceptions of the roles of numbers in health that have been found in general populations. In addition we found similar themes across English and Spanish-speaking groups. The findings reflect perceptions of the value and limitations of the use of numbers in health among this community.
Despite these limitations, our study supports the relevance of elements of existing frameworks of health numeracy for this population while adding emphasis to other important themes. In particular, our findings emphasize the affective and cognitive responses that can influence the application of numeric information in the context of health.
These findings suggest avenues for interventions to improve patient physician communication. Health communicators can take advantage of attributes of numbers such as clarity and perceived objectivity, to communicate more effectively with patients. However, time and attention are also needed to explain the meaning of numeric information and address concerns regarding how and why general numeric information is applicable to an individual. Empiric cross cultural studies will increase the validity of the health numeracy construct across diverse populations.