Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.


Health Promotion and Behavioral Sciences

Degree Program

Public Health Sciences with a specialization in Health Promotion, PhD

Committee Chair

Wilson, Richard W.

Committee Co-Chair (if applicable)

Klein, Paul

Committee Member

Roelfs, David

Committee Member

Rowland, Michael


Health literacy; Parents of chronically ill children; Mathematical ability


Health numeracy, a counterpart to health literacy, can be a mediator of health disparities. This study analyzed the impact of both cognitive and affective numeracy on the pathway linking health behavior to health outcomes, and the role of self-efficacy in this relationship, based on the Health Belief Model. The context was parental management of children's complex diets that require numerical calculations. Parents of children ages 12 months to 12 years with type 1 diabetes (T1D) or phenylketonuria (PKU) were recruited at clinics or community events in east-central states. Ninety-eight participants completed a standardized test of math skills, an instrument to assess attitudes and emotions towards mathematics in daily life, and a questionnaire on parental self-efficacy of caring for a child with T1D or PKU. Health outcome was evaluated via hemoglobin A1c or blood levels of phenylalanine. Engagement was measured by number of blood levels taken during glucose or phenylalanine monitoring, compared to clinic recommendations. Factor analysis indicated affective numeracy was a significant component of the overall variable numeracy. Structural equation modeling did not support a relationship between any variable and health outcome, although bivariate analysis suggested significant relationships between poor math skills, low self-efficacy, less engagement, low income, less education, or more years on the diet, and poor metabolic control. In pathway analysis, cognitive numeracy had a strong positive relationship with engagement, while affective numeracy had an equal but negative predictive effect. Adjustments to the model identified education as the ultimate driver of the relationship. Parental self-efficacy was not a mediator between numeracy and health outcomes or engagement. The relationship between self-efficacy and engagement was strongly influenced by other pathway variables, and parental self-efficacy was significantly lower when the child had been on the diet for a longer time. This study asserts the importance of affective component of numeracy along with cognitive skills, and offers a validated instrument for assessment. Treatment programs for PKU and T1D should recognize that parents with lower numeracy skills and discomfort with math are at risk for less engagement. Further research is needed to clarify the path by which numeracy impacts health outcomes.

Included in

Public Health Commons