Health numeracy is a component of health literacy and can be defined as “the degree to which individuals have the capacity to access, process, interpret, communicate, and act on numerical, quantitative, graphical, biostatistical, and probabilistic health information needed to make effective health decisions.”1 Health numeracy skills can be broadly categorized into four categories: (1) basic (eg, identifying numbers), (2) computational (eg, counting, quantification, or simple manipulations), (3) analytical (eg, using higher-level concepts such as inference, estimation, and frequencies), and (4) statistical (eg, understanding basic biostatistics such as probability statements, proportions, percentages, and risks).1

Numeracy is deeply integrated into the role of a health care provider and forms the basis of practicing evidence-based medicine (EBM).2 EBM incorporates various factors into clinical practice, including clinical epidemiology, biostatistics, research methods and medical informatics.3 The Royal College of Physicians and Surgeons of Canada introduced the CanMEDS Framework4 to outline the core competencies for medical education and practice in Canada. According to the CanMEDs Framework, health care providers (particularly physicians) need to possess the skills to “identify pertinent evidence, evaluate it using a specific criterion, and apply it in their practice and scholarly activities.” Building from this definition, health care providers must be able to interpret numerical data and extrapolate results to guide evidence-based clinical decision making and best practices. Arnold et al5 suggested that with the substantive increase in the presence and complexity of statistical information in medical literature, clinicians need more than basic statistical concepts and require a “comprehensive understanding” to “effectively read and use medical research.”

Despite health care providers attaining a high level of education, several studies have found that many still struggle with numeracy.6 A cross-sectional study by Windish et al7 found that, of the 277 internal medicine residents surveyed, less than half were able to correctly interpret statistics in medical literature. A study conducted by Garcia-Retamero et al8 focused on risk literacy in surgeons and found that 62% of surgeons in high-income countries have low-to-moderately-low numerical skills. Additionally, Eastwood et al9 identified a “potentially dangerous level” of mathematical deficiencies, including basic concepts in problem solving and formulation, in nursing students at a university in Australia, with participants scoring an average of 56.1% on a drug calculation assessment. Similarly, Jukes et al10 assessed the drug calculation skills of nursing students at a university in the United Kingdom. This study found significant issues in computational and conceptual abilities, with their sample of nursing students achieving a mean score of 55% on a 10-item drug calculation test. Numeracy issues related to drug calculations and medications errors are now commonly recognized11; however, deficient numeracy skills extend far beyond, including interpretation of diagnostic results, other medical computations (eg, fluid balance, nutritional needs, flow rates), and interpreting research evidence. These skills are especially important in high-pressure and fast-paced environments, such as the emergency department or a surgical operating room, where inaccuracies can significantly affect patient safety and result in adverse outcomes.11

Furthermore, to provide person-centered care and effectively communicate accurate numerical information to patients, such as risks and benefits of treatments or medication dosing, health care providers must themselves possess a strong foundation in these skills.12,13 A study by Petrova et al14 found that physicians with higher numeracy skills were more likely to communicate complete and balanced information regarding screening tests to patients.

The numeracy skills of health care providers are especially important, given the high rate of low numeracy skills among patients. A study by Rothman et al15 assessed 200 patients of a primary care practice on their interpretation of food labels. Although 75% of patients reported at least high school education, only 37% possessed ninth-grade math skills as assessed by the Wide Range Achievement Test (WRAT-3). Similarly, a study by Sheridan et al16 assessed the numeracy level and risk interpretation ability of 357 participants attending a university internal medicine clinic. Of the participants, 70% perceived themselves to have good numeracy skills; however 71% answered only one or no questions correctly on a three-item general numeracy assessment. In this same study, more than half of participants failed to correctly identify which of two treatments provided greater benefit when presented with hypothetical risk information.

Patients navigating the health care system are constantly faced with numerical information, and numeracy plays a vital role in their decision making. Limited numeracy skills can affect a patient's abilities to make informed choices, impairs risk communication, limits medication compliance and access to treatments, and can negatively affect their medical outcomes.17

This increases the importance of health numeracy skills among health care providers who can serve as resources to help patients understand and use numeric information.17

Given the evolving role of health care providers and the increasing demands on providers to interpret and communicate numerical information, educational curricula need to adapt to incorporate these concepts. Recent calls for a new definition of basic and clinical sciences in medical education18 should be considered in curricular planning, with numeracy realized as a foundational skill that enables logical reasoning, critical appraisal, clinical decision making, and improved communication.19 Although education in numeracy is often integrated into health care provider training curricula, the approach to teaching, competencies covered, student satisfaction, and overall effectiveness of these educational interventions varied. Ideally, the integration of this content is provided in a way that promotes mechanistic understanding, and fosters improved understanding, reasoning, and communication.20,21 The goal of this scoping review was to explore and summarize what is known about numeracy skills education programs for health care providers.

METHODS Search Strategy

A comprehensive literature search was conducted by a medical librarian (R.F.) for publications in Medline ALL (Medline and Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, Emcare, and PsycInfo all from the OvidSP platform; ERIC from EBSCOhost; Scopus from Elsevier; Web of Science from Clarivate Analytics; and Global Index Medicus from WHO. The search was initially limited to publications from January 1992 to April 2021 based on the emergence of the concept of evidence-based medicine, but this was later refined to publications between January 2010 and April 2021, given the 2010 recommendations for reform in medical education.22,23 Where available, both controlled vocabulary terms and text words were used in the subject block structure, such as health personnel/educator terms included in one block, education/pedagogy terms contained in the second block, numeracy and relevant synonymous terms comprising the third block. Wherever applicable, the search was restricted to human studies, adults (age older than 18 years), and the English language. Supplemental Digital Content 1 (see File 1, https://links.lww.com/JCEHP/A222).

Article Selection and Eligibility

Citations of articles for screening were managed and stored in Endnote,24 a reference manager, and Covidence,25 an online systematic review manager and screening tool. Procedures as outlined in the Joanna Briggs Institute methods26 for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews27 were followed. To determine article eligibility, a two-stage screening process was conducted guided by an a priori protocol. The initial stage consisted of a title and abstract scan to determine relevant studies for inclusion in the subsequent full-text review and data extraction. Two of four reviewers (C.G., B.J., R.M., Q.W.) performed title and abstract scanning, full-text review, and data extraction independently. After each stage, discrepancies were resolved by a fifth reviewer (J.P.). Titles were scanned, and when relevance could not be determined based on title alone, the abstract was reviewed. Articles meeting the inclusion criteria were reviewed in full. Six hundred eleven articles met the inclusion criteria for full-text screening; however, 39 full-text articles were unable to be retrieved. A flow diagram was created according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines28 to demonstrate the review process, including number of studies identified, screened, found to be eligible, and included in the review.

Inclusion Criteria

This review was limited to studies published in English and restricted to adult populations (age older than 18 years). Studies were included if they were (1) related to numeracy education or skills, (2) in the setting of a training program or educational intervention, (3) in the setting of education of health care providers (continuing professional development/continuing medical education) or health care providers in-training, (4) in the setting of health care professions involved in human medicine, and (5) provided sufficient details regarding methods, evaluation, and results. Given the role numeracy plays in all aspects of health care and guided by the regulated health professions within Canada, the research team defined the term “health care providers” to include audiologists, chiropodists, chiropractors, dental hygienists, dental technologists, dentists, denturists, dietitians, homeopaths, kinesiologists, massage therapists, medical laboratory technologists, medical radiation technologists and sonographers, midwives, naturopaths, nurses, occupational therapists, opticians, optometrists, pharmacists, pharmacy technicians, physicians, physiotherapists, podiatrists, psychologists, psychotherapists, respiratory therapists, speech-language pathologists, traditional Chinese medicine practitioners and acupuncturists, personal support workers, physician assistants, physiotherapy assistants, and social workers.

Exclusion Criteria

Studies excluded in this review included research in progress, conference proceedings/abstracts, dissertations/theses, books/book chapters, and systematic/literature reviews.

Data Extraction

Data were extracted from the articles and charted, then summarized according to the guidelines by Arksey and O'Malley.29 The data extracted from each article included (1) general information (title, author, publication year, country, and setting), (2) study methods (objectives, design, and data collection method), (3) participant characteristics (sample size and population type), and (4) findings (numeracy concept, intervention type, intervention length, and main findings).

Data Analysis

Numeric analysis (count data) was used to summarize general study details (country, setting, and design), intervention characteristics (numeracy concepts, length, and teaching modality), participant characteristics (sample size and population type), and study outcomes. To determine study outcomes, an inductive approach was used to collate recurrent themes. Four major outcome categories were determined.

RESULTS

The literature search retrieved 31,607 results and four additional studies were identified via hand-combing of literature review reference lists. After removing duplicates, 26,147 studies remained. After title and abstract scan, 25,536 articles were excluded, leaving 611 for full-text review. An additional 540 studies were excluded after full-text review because of publication date, language, study population, study type, study focus, and study setting. During full-text review, 11 additional duplicates were identified and removed. Seventy-one articles remained that met the eligibility criteria and underwent data extraction. See Figure 1.

FIGURE 1.: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)28 flow diagram.Numeric Analysis

Of the 71 studies retrieved from the literature search, 55 (77%) were quasi-experimental, eight (11%) were experimental, and eight (11%) were classified as “other,” which included qualitative studies using grounded theory and mixed methods studies. The majority of studies were conducted in the United States (n = 24, 34%). Twelve (17%) studies were conducted in Australia, 10 (14%) in the UK, six (8%) in Canada, three (4%) in Iran, two (3%) in Germany, two (3%) in the Netherlands, and 15 (21%) in other countries, including Brazil, Thailand, Syria, Qatar, China, Ukraine, Croatia, India, Spain, Pakistan, Israel, Germany, Serbia, and Tanzania. Most of the studies (n = 60, 85%) were conducted in a university setting and 11 (15%) were conducted in a hospital.

The average sample size was 180 (SD = 215, range = 3–1035). A majority of educational interventions were provided for health care trainees (n = 64, 90%), six (8%) for health care providers continuing professional development, and one (1%) included both trainees and health care providers. Twenty-three (32%) studies focused on interventions for nursing students, 15 (21%) for medical students, seven (10%) for resident physicians, six (8%) for pharmacy students, and three (4%) for nurses. Four (6%) of the studies targeted more than one group of health care providers, such as nursing students and paramedicine students.30 The remaining 13 studies (18%) focused on other health professions and trainees, including physicians, dental hygiene students and dental students, social work students, physiotherapy students and physiotherapists, speech-language therapy students and speech-language therapists, and pharmacy residents. Supplemental Digital Content 2 (see File 2, https://links.lww.com/JCEHP/A223).

Thematic Analysis

Although there is significant overlap between concepts in numeracy, a slight majority of studies focused on teaching a single concept (n = 37, 52%), and the remaining studies (n = 34, 48%) integrated multiple concepts within their curriculum. The numeracy skills most commonly included were statistics and biostatistics (n = 34, 48%), followed by medication calculations (n = 23, 32%), EBM (n = 22, 31%), research methodology (n = 16, 23%), epidemiology (n = 8, 11%), mathematics (n = 7, 10%), general numeracy (n = 6, 8%), and critical appraisal (n = 4, 6%). Additionally, common numeracy topics appeared in educational interventions depending on health care provider subspeciality. Of all the interventions for nursing students and nurses, the majority focused on medication calculations (n = 19, 73%), whereas statistics and biostatistics were the most common concepts appearing in educational interventions for resident physicians (n = 6, 86%), medical students (n = 12, 80%), and pharmacy students (n = 3, 50%; Figure 2).

FIGURE 2.:

Common numeracy concepts per health care provider specialty. Note: Each study may focus on more than one numeracy concept.

The length of the educational interventions in the reviewed studies ranged from a minimum of 2 hours for one half-day course31 to a maximum of 230.5 hours over 6 years in one longitudinal course spanning the length of a medical school curriculum.32 Many of the studies (n = 48, 68%) did not specify the number of teaching hours included in the educational intervention.

A variety of teaching modalities were used, with 21 (30%) studies using both passive learning techniques (eg, traditional lectures and didactic teaching) combined with a more active learning approach (eg, workshops, laboratories, small-group exercises, discussion boards). Twelve studies (17%) used a computer/web-based application or program to support their teaching. Several other modalities were used, such as blended learning (n = 7, 10%), journal club (n = 4, 6%), problem-based learning or case-based learning (n = 4, 6%), dimensional analysis (n = 3, 4%), flipped classroom (n = 2, 3%), and lectures alone (n = 2, 3%). Supplemental Digital Content 3 (see File 3, https://links.lww.com/JCEHP/A224).

Most of the studies measured multiple specific outcomes, which can be more broadly categorized into the following outcome categories: knowledge and skills, self-efficacy, attitudes (including perceptions and course evaluations), and engagement. The most examined outcome was knowledge and skills (eg, medication calculation skills and statistics interpretation), which were assessed in 56 studies (79%). The next most measured outcome was attitudes (eg, fear, anxiety, preferred learning and teaching styles, perceived utility and benefit of course33; n = 32, 45%), followed by self-efficacy (including confidence level; n = 23, 32%). The least commonly measured outcome category was engagement (eg, participation in online discussion boards, participation in class activities, engagement with online lessons; n = 2, 3%). Nearly all studies (n = 70, 99%) showed improvement in at least one of their measured outcomes categories.

DISCUSSION

This review has summarized the findings of 71 studies regarding a variety of educational interventions and teaching methods used to build numeracy skills of health care providers. Key findings are discussed below: (1) the need for more professional development opportunities to support numeracy skills retention; (2) the value of novel forms of learning that transcend the confines of the classroom; (3) the necessary trend away from memorization to conceptual understanding in numeracy; and (4) the dearth in curricula focused at applying numeracy skills in patient-provider communication.

The majority of numeracy skills building interventions were directed toward health care students in university settings, which may be skewed by the convenience of recruiting student participants. Few studies included follow-up on long-term retention, however, and this may vary significantly between intervention types. A study by Bell et al34 provided an online diabetes tutorial to resident physicians and found that although their mean knowledge scores increased from 50% to 75% immediately following the intervention, there was no significant measurable retention when retested at 55 days. This same study emphasizes the inherent properties of human memory, whereby newly learned knowledge must be exercised regularly to remain accessible. Ideally, to ensure retention of these skills down the line, numeracy education should be incorporated into continuing professional development and continuing medical education programs.

Nearly all studies included in this review described improvements in numeracy outcomes from baseline, regardless of intervention modality. Major differences stemmed from learner satisfaction and feedback. Generally, learners expressed satisfaction and enjoyment and improved outcomes from interventions that promote active engagement in the course material and integrated multiple approaches to the learning process (eg, lectures, hands-on workshops, small group learning, team-based learning, contextual exercises, and web resources). This result is consistent with the sentiments noted in a report by Frenk et al,23 wherein successful educational programs used multiple learning channels. Frenk et al23 noted an unprecedented increase in the volume of, and access to, information and recommended that educational institutions need to broaden their approach to “incorporate novel forms of learning that transcends the confines of the classroom.” The same report suggested moving away from the lecture-based didactic method, and instead, striving toward a competency-based approach with team-based learning. It should be noted that because the majority of studies included in the review employed pre-post quasi-experimental designs, improvements may be attributed to the process of pretesting and the subsequent influence this can have on results. This is because there was no baseline measurement taken against groups that remained completely unexposed to the numeracy intervention.

An essential component of educating health care providers in basic sciences and foundational skills, such as numeracy, is to ensure they are able to transfer this knowledge to future clinical problems in real-world scenarios.21 However, there is limited research regarding the effectiveness of educational interventions on the abilities of health care providers to transfer their foundational knowledge to real-world clinical reasoning.21 Fortunately, given the extensive research into the best practices of mathematical and numerical instruction for kindergarten to grade 12 students, the same concepts can serve as a guide to determining effective methods to improve numeracy skills in health care providers. In the past, numeracy education had a strong focus on memorization of basic mathematical facts and procedures35,36; however, more current research has emphasized the importance of conceptual understanding.37 A report from the National Research Council36 described mathematical proficiency as consisting of “five strands,” including conceptual understanding, procedural fluency, strategic competence, adaptive reasoning, and productive disposition. These five strands are “interwoven and independent” and optimal instruction should address each strand. A balanced instructional approach can help equip students with effective mathematical reasoning skills and the ability to tackle unfamiliar and challenging tasks.37 A similar sentiment was emphasized in a report from the National Science and Technology Council,38 which suggested that contextual learning with “emphasis on logic, reasoning, and critical thinking” better equips learners with numerical skills for real-world application. A report from Lawson39 recommended an optimal instructional approach whereby teachers apply a variety of strategies, avoiding direct memorization of facts, and instead present problems for students to work through and practice in different contexts. This is further supported by recommendations for a focus on “concepts and strategies, engaging in discussions, and practicing with feedback” to develop mathematical proficiency.36 This review has outlined several education interventions for health care providers with a variety of education approaches. Given the evidence of poor health care provider numeracy skills, the best practices of mathematical education in primary and secondary school can serve as a framework to guide future numeracy programming for health care providers.

A review by Rothman et al15 discovered a general deficit in the numeracy skills of patients, especially in the context of health care, and that these deficits may be contributing to adverse outcomes. Additionally, Apter et al12 further noted that limited numeracy skills hinder a patient's ability to communicate with health care providers, their ability to understand health information and to make decisions regarding their health care. The same study also noted the importance of communication of numerical concepts to patients and how improvements in the skills of health care providers in this area can enhance the quality of medical care provided. A study by Howard et al40 found that health care providers tend to overestimate their ability to clearly communicate with patients and do not routinely apply recommended communication techniques with their patients. To provide person-centred care and encourage shared decision making, health care providers must possess skills to interpret numerical information and the ability to effectively communicate this information to patients and their families. Increased awareness and training for health care providers in numerical communication may help to close this gap and improve health outcomes. This review has identified a notable deficiency in training programs and curricula focused on improving health care provider's ability to communicate numeracy concepts to patients and their families.

PRACTICAL IMPLICATIONS AND FUTURE RESEARCH

Future research examining the extent to which the accreditation bodies have recognized the need for numeracy skills in health care providers would be helpful in clarifying expectations in learning outcomes. It is intended that the findings of this scoping review will be used to develop a numeracy education course for health care providers to help achieve this goal.

Study Limitations

Limitations of this study have been identified and can serve as a steppingstone for future research. This review is limited to studies published in the English language, with the majority published in North America (specifically the United States), which may result in a lack of generalizability. Additionally, this review focused on studies that provide sufficient details regarding methods, evaluation, and results methods and has excluded commentary and editorials. In an effort to minimize personal bias in data extraction, reviewers performed source selection independently, with any dispute resolved by an independent reviewer. The authors have not received funding or support and have no disclosures to report.

CONCLUSIONS

This review provides a summary of the educational interventions and teaching methods involved in numeracy education for health care providers. Nearly all studies included in this review described improvements in participants' numeracy outcomes, regardless of intervention modality. Major differences arose in learning satisfaction and feedback, with improved outcomes from interventions promoting active engagement in the course material and integrated multiple approaches to the learning process. Although efforts have been made to incorporate numeracy and EBM into training curricula, greater emphasis should be placed on developing strong numeracy skills in health care providers, particularly given the role numerical information plays in their clinical decision making, evidence-based best practices, and patient-provider communication.Lessons for Practice ■ Greater emphasis should be placed on developing strong numeracy skills in health care providers, given the role numerical information plays in clinical decision making, evidence-based practices, and patient-provider communication. ■ Numeracy education should be incorporated into continuing professional development and continuing medical education programs to ensure long-term retention. ■ Increased awareness and training for health care providers in effective numerical communication to patients and their families may help to encourage shared decision making and person-centred care.

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