Many adults struggle with the specialised skill of health literacy. Health literacy is defined by the Australian Bureau of Statistics (ABS) as, ‘the knowledge and skills needed to understand and use information relating to health issues such as drugs and alcohol, disease prevention and treatment, safety and accident prevention, first aid, emergencies and staying healthy’. ABS data derived from the 2006 Adult Literacy and Life Skills Survey (ALLS) survey shows that 59% of Australian adults lack the minimum health literacy skills needed to cope with everyday life (ABS 4223.0 Health Literacy). This means that 3 out of 5 Australian adults has difficulty using everyday health information to make good healthcare decisions.
Diabetes numeracy skill demands
For people with diabetes, their health literacy skills needs are even more specialised – they need diabetes literacy skills, and in particular, diabetes numeracy skills.
Diabetes management involves significant numeracy skill demands and studies show that low levels of numeracy skills are associated with poorer levels of treatment adherence, blood sugar control, and diabetes knowledge.
Examples of the types of diabetes numeracy challenges that some people have been found to struggle with include:
- Interpreting blood glucose readings
- Reading and interpreting product food labels
- Calculating the carbohydrate content of foods
- Interpreting serving sizes
- Calculating insulin doses
- Understanding and making judgements about short term and long term risks
Diabetes numeracy is complicated by its real-world application where diabetes numeracy tasks must be performed amid the hustle and bustle of daily life, independently, with limited access to support, and with the added pressure that errors may have serious health consequences.
Diabetes numeracy and the ACSF
Diabetes numeracy skills include all three ACSF numeracy indicators, often in combination. For example, the task of measuring blood glucose levels demands:
- Numeracy skills to read and understand blood glucose measurements, the terminology used, safe and unsafe blood glucose levels and the units of measurement, mmol/L (ACSF numeracy indicator .09)
- Numeracy skills to use a blood glucose metre, take accurate blood glucose measurements, check the results against safe ranges and reflect on whether the readings are reasonable (ACSF numeracy indicator .10)
- Numeracy skills to record the measurements and talk about the results, how they were produced and what they mean using specialised blood glucose measurement terminology (ACSF numeracy indicator .11)
The diabetes numeracy skills demands are complex, not only because of the mathematical knowledge and skill demands, but also because:
- The numeracy demands are highly contextualised, integrated with diabetes knowledge and broader health literacy concepts
- The numeracy demands include interpreting, analysing, evaluating and using mathematical information to solve problems and make decisions
- The consequences of miscalculations and misunderstandings pose significant short and long term health management risks that need to be considered
- Day to day management of diabetes is an individual responsibility
Diabetes numeracy demands align with ACSF level 4 and ABS data shows that only 5.8% of Australian adults perform at this level.
Skills application
As part of the Diabetes Victoria education program I have been involved in over the past couple of years, participants are given exercises to practise the skills they need in daily life. An example of one of the exercises is to determine the amount of carbohydrate in a date pudding recipe. In this exercise the participants are given a copy of the date pudding recipe and a list of common food items showing the amount of carbohydrate they contain by serving size.
The numeracy skills required for this exercise are as follows.
Numeracy indicator .09 – Participants need to read and interpret the mathematical information in the recipe text to understand:
- How to follow a recipe text
- The language of measurement (e.g. Weight is measured in grams, ‘g’ is an abbreviation for grams)
- Amount of food expressed by count (e.g. 2 eggs), volume using different units of measurement (e.g. teaspoons, cups and mL) and weight using grams
- Number of serves and serving size
- What information is relevant to the exercise (for example, ingredients, amounts and serves) and what is irrelevant (method, source)
- How to navigate the food list and interpret quantities by count, volume and weight and carbohydrate amounts in grams (for example, 1 cup of plain flour contains 95 grams of carbohydrate)
- Using the food list to identify the ingredients that contain carbohydrate
- Using the food list to look up the amount of carbohydrate in a quantity of the ingredient
- Calculate the amount of carbohydrate per ingredient in the recipe
- Calculating the total carbohydrate in the recipe
- Rounding to whole numbers
- Using the number of serves to calculate amount of carbohydrate per serve
- Using calculators to calculate
- Using estimation and reflecting on the reasonableness of calculation results
Numeracy indicator .11 – Participants need to be able to discuss the information in the classroom setting using the specialised language and use written mathematical language to represent the problem-solving process and the final result.
The list of numeracy skills required for the task looks daunting and a significant amount of pre-teaching using a scaffholded approach is required to build skills and confidence. Pre-teaching also needs to be at a suitable pace and respectful of those participants who may struggle with maths anxiety and are particularly at risk of disengaging. Suggestions include starting with a simpler recipe with only two ingredients only, amounts expressed by count only, amounts that are easy to lookup in the food list, whole numbers only and a single serving size. For example, an egg on toast, no butter. Introduce another recipe, more ingredients, different ways of expressing amounts, whole numbers only and a single serving size. For example, a homemade pizza for one. Then, introduce a recipe with more than one serving using amounts and serving sizes and then start introducing decimals and rounding. For each level of skill, include worked examples and a practice activities. Finally introduce the very real example of the date pudding recipe exercise and consolidate the learning.
Framing health risks
Framing is the way in which information is presented. A framing effect is a problem that happens when equivalent information is interpreted differently because it’s presented differently. A familiar example is the glass half empty and the glass half full – mathematically equivalent information presented differently with different interpretations.
Understanding framing effects is critical in health literacy. Health information is often about risk and the mathematical knowledge and skills area of probability (and therefore risk) is poorly understood. For example, many adults do not know that 1 in 10 and 10 in 100 represent equivalent risks believing the second option represents a higher risk. When presented with risks of 1 in 10 and 1 in 20, many people think the second option represents the higher risk because 20 is bigger than 10. Also, to further complicate matters, we are biased towards the positive. For example, given the choice of a 10 % risk of dying versus 90 % probability of surviving many people see the second option as more favourable.
Even without using numbers, understanding and talking about risk is challenging because probably has its own mathematical language. This language includes everyday terms such as likely, unlikely, very likely, very unlikely, possibly, greater chance, lesser chance, probability, probably not, certain and uncertain. These are terms are familiar to most people who speak English and hide in everyday texts in plain sight. However, they should not be underestimated as the numeracy skills needed to understand the mathematical information embedded in texts containing this language is aligned to the numeracy core skill at ACSF level 3.
Also, the health risks associated with decisions people make are short term (for example, drink alcohol and you risk a hangover) or long term (for example, drink alcohol and you risk developing liver disease). The same is true for diabetes. In the short term, a person with diabetes whose blood glucose levels are not managed risks hypoglycaemia and in the long term, they risk blood vessel damage. We also tend to make health behaviour decisions based on short-term risks, for example, deciding to drink alcohol and risk a hangover without considering the long-term risk of liver disease.
To make decisions that promote good health and prevent disease, people need to be able to judge short term and long term health risks. Effectively framing health risk information involves:
- Communicating risk information carefully by using common denominators (for example, 2 in 20 and 1 in 20 instead of 1 in 10 and 1 in 20)
- Communicating visually
- Adding qualitative information (for example, ‘as few as 1 in 20…’)
- Managing bias by advising people what they should do, rather than what they shouldn’t (for example, ‘manage your blood sugars to prevent blood vessel damage’)
Concluding comments
As a practitioner with many years’ experience working in health education and vocational training, I believe that there is much work to be done developing and reinforcing the necessary skills for maintaining day to day health and long-term risk prevention for everyone, but particularly for people living with chronic disease. We can all be more aware and adept at providing support through greater awareness of the numeracy and literacy skills needed to live a long and healthy life.
References
Australian Bureau of Statistics. (2006). Health Literacy, Australia, 2006 (cat. no. 4233.0). Canberra, Australia: Author.
This article first appeared in Fine Print in 2017 published by the Victorian Adult Literacy and Basic Education Council Inc.
About Tina Berghella
Tina Berghella is the secretary of the Australian Workplace Practitioner’s Network and a former member of the National Foundation Skills Strategy Project’s Community of Practice. She has developed numeracy test items for the Foundation Skills Assessment Tool (FSAT) and delivered workplace literacy and numeracy training programs. Tina has conducted NCVER funded research exploring the numeracy skills of the VET workforce and is the author of a suite of professional development resources designed to build the workplace numeracy awareness and skills of VET practitioners.