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Risk information may be interpreted differently by people with diabetes due to differences in age, gender, ethnicity and so forth (Schillinger et al., 2002;

Paasche-Orlow et al., 2005). Studies show, for example, that patients with lower

levels of health literacy were less likely to be fully involved in decision-making about their own health (Schillinger et al., 2002; Paasche-Orlow et al., 2005).

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Furthermore, they were more likely not to adhere to prescribed treatment and more likely to have poor diabetic control compared with patients with higher

levels of health literacy (Schillinger et al., 2002; Paasche-Orlow et al., 2005).

Even when information is given, not all patients may interpret such information in the same way because of other factors that impact on these decision-making processes, which can be linked to past experiences, perceived levels of complexity and urgency together with patients’ tacit and explicit knowledge in relation to the topic (Gigerenzer and Edwards, 2003). These interpretations apply not only in terms of literacy but also in terms of numeracy, which is also related to individuals’ ability to process complex information. These kinds of issues affect risk communication efforts and can be a significant challenge to Health Care Professionals. Alongside this, there are patients whose cultural traditions make it more likely that they lack experience in relation to autonomous decisions and so tend to base their decisions on the views of their Health Care

Professionals (Elwyn et al., 2012). Health Care Professionals, therefore,

increasingly acknowledge that patients base their interpretations of the information provided on a wide range of factors and it is this variation within patient interpretation that results in Health Care Professionals not supporting

the principle of having a standard risk message (Edwards et al., 1998a).

For example, Edwards et al. (1998a) conducted a qualitative study using six

semi-structured focus groups to explore current practice regarding the communication about risk. Thirty six Primary Care Professionals were recruited including general practitioners, practice nurses, district nurses, community psychiatric nurses, and health visitors. The sample structure was designed to enable a comparison to be made between professionals and to ascertain whether there were any differences in their attitudes to risk communication.

Edwards et al. (1998a) found that although Health Care Professionals

supported the idea of using standardized communication techniques, because they felt it had benefits in making professionals consistent, they did not support the idea of standardizing the language of communication because of discrepancy in the interpretation of risk data by patients.

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It is also important to note that the ways in which individuals interpret the information provided is also related to the ways in which Health Care Professionals adequately explain health information and not simply the ways in which patients interpret or understand such information. A number of studies have examined the ways in which variances in the ways in which numeracy is

used by physicians can impact on this process. For instance, Cokely et al.,

(2012) reported that many physicians did not understand relevant numerical information, which decreases their ability to accurately interpret and inform their patients about their risk. A systematic review conducted by Anderson and Schulkin (2014) shows that 53-75% of physicians’ samples are not able to appropriately answer questions about basic probabilities, which limited their ability to convert probabilities into frequencies and percentages for their patients. In addition, a randomised control trial conducted by Garcia-Retamero and colleagues assessed numeracy and risk literacy in a diverse group of practicing surgeons, to investigate whether using transparent visual aids improved surgeons’ risk comprehension and to investigate changes in surgeons’ risk comprehension process. Surgeons were asked to complete a two-part computer-based questionnaire. In the first part, they provided demographic information. They also completed the Berlin Numeracy Test, a validated, psychometric research instrument designed to measure numeracy and predict risk literacy in educated samples from diverse countries. In the second part of the questionnaire, surgeons were presented with a scenario describing the results of a randomised controlled trial testing side effects of new type of anaesthesia in patients who underwent surgery. The task involved

realistic risk information taken from a published study (Davis, et al., 1989) that

was selected to be representative of the type of information that practicing surgeons would routinely encounter and evaluate in due course of continuing medical education and professional development. The results show that 50% of the surgeons were classified in the first (lowest) level of numeracy, 20% were classified in the second level, 14% were classified in the third level, and 16% were classified in the fourth (highest) level of numeracy. Despite the fact that surgeons from developed countries had higher levels of numeracy, compared with surgeons from developing countries, the results showed that 37% of surgeons from developed countries had limited numerical skills. Surgeons with

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limited numeracy skills were unable to correctly interpret the risk without additional help. However, visual tools made risks more clearer and eliminated differences in understanding between surgeons who had high levels on numeracy and those with low levels of numeracy. Therefore, risk tools can be an effective tool in improving risk understanding among Health Care Professionals with mixed numeracy abilities.