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Does Numeracy Correlate with Measures of Health Literacy in the Emergency Department?
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  • Description:

    To quantify the correlation between general numeracy and health literacy in an emergency department (ED) setting.


    This was a prospective cross-sectional convenience sample study of adult patients in an urban, academic ED with 97,000 annual visits. General numeracy was evaluated using four validated questions; and health literacy using three commonly used validated screening tools (Short Test of Functional Health Literacy in Adults [S-TOFHLA], Rapid Estimate of Adult Literacy in Medicine-Revised [REALM-R], and the Newest Vital Sign [NVS]). Scores were dichotomized for health literacy tests to limited (low or marginal) vs. adequate health literacy, and the proportion of patients answering all numeracy questions correctly were calculated with the mean proportion of correct responses in these groups. The correlation between numeracy scores and scores on the health literacy screening tools was evaluated using Spearman's correlation.


    Four hundred forty-six patients were enrolled. Performance on questions evaluating general numeracy was universally poor. Only 18 patients (4%) answered all numeracy questions correctly, 88 patients (20%) answered zero questions correctly, and overall the median number of correct answers was one (IQR 1 to 2). Among patients with limited health literacy by any of the three screening tools used, the mean number of correct numeracy answers was approximately half that of patients with adequate health literacy. However, even among those with adequate health literacy, the average number of correct answers to numeracy questions ranged from 1.6 to 2.4 depending on the screening test used. When dichotomized into those who answered ≤50% vs. >50% of numeracy questions correctly, there was a significant difference between those with limited health literacy and those who scored ≤50% on numeracy. Health literacy screening results were correlated with general numeracy in the low to moderate range: S-TOFHLA rs = 0.428 (p < 0.0001); REALM, rs = 0.400 (p < 0.0001); and NVS, rs = 0.498 (p < 0.0001).


    Correlations between measures of general numeracy and measures of health literacy are in the low to moderate range. Performance on numeracy testing was nearly universally poor, even among patients performing well on health literacy screens, with a substantial proportion of the latter patients unable to answer half of the numeracy items correctly. Insofar as numeracy is considered a subset of health literacy, these results suggest that commonly used health literacy screening tools in ED-based studies inadequately evaluate and overestimate numeracy. This suggests the potential need for separate numeracy screening when these skills are important for health outcomes of interest. Providers should be sensitive to potential numeracy deficits among those who may otherwise have normal health literacy.

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  • Funding:
    1KM1CA156708-01/CA/NCI NIH HHS/United States
    3U54CA153460-03S1/CA/NCI NIH HHS/United States
    KL2 RR024994/RR/NCRR NIH HHS/United States
    KM1 CA156708/CA/NCI NIH HHS/United States
    KM1CA156708/CA/NCI NIH HHS/United States
    P30 DK092950/DK/NIDDK NIH HHS/United States
    P50 CA95815/CA/NCI NIH HHS/United States
    R01 CA168608/CA/NCI NIH HHS/United States
    R21 HS020309/HS/AHRQ HHS/United States
    TL1 RR024995/RR/NCRR NIH HHS/United States
    U58 DP0003435/DP/NCCDPHP CDC HHS/United States
    UL1 RR024992/RR/NCRR NIH HHS/United States
    UL1 RR024992/RR/NCRR NIH HHS/United States
    UL1 TR000448/TR/NCATS NIH HHS/United States
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