Writing and Designing Effective Communication: A Comprehensive Course

From left to right: Janet Ohene-Frempong, MS, Jann Keenan, EdS

From left to right: Janet Ohene-Frempong, MS, Jann Keenan, EdS

Jann Keenan and Janet Ohene-Frempong gave a daylong workshop. They provided detailed strategies for how to communicate effectively through both print and online materials. They used samples to illustrate what works and what doesn’t work.

“Health literacy is a subset of health communication,” said Ohene-Frempong. “How we communicate — across all these different media — that’s the issue. The other issue is navigation.”

The presenters explained the reader-centered approach: to engage, support, and motivate readers. And they offered tips for how to implement this approach.

We all have our preconceptions and ignorance. “Each of us is in our own little universe,” said Ohene-Frempong. “That’s why you need to check with the end-user.”

The presenters discussed how to write effective materials. They offered tips on content, organization, and style. They also discussed effective design and page layout.

It’s important to raise awareness in your designer about why design needs to be done a certain way. “You need to get buy-in early on,” Keenan said.

“There tends to be a tension between information and space,” said Ohene-Frempong. “If the information you’re giving readers is crucial, you don’t want to cut out information just to make space. You need to be an advocate for your reader.”

The presenters explained how to assess the readability of text and design and told how to use readability tools and field-testing. They discussed how to revise text and design to improve readability. They also told how to plan a writing project.

The workshop included two group exercises: a writing exercise and a revising exercise. The presenters led the group through the exercises step by step.

“If you have one takeaway from today, it’s that you really have to write for your reader — write for your end-user,” said Keenan. “That’s the only way to make the material clear and effective.”

Cultural Competency and the CLAS Standards

Marian Ryan, PhD, MA, MPH, CHES

Marian Ryan, PhD, MA, MPH, CHES

Marian Ryan began the session with a discussion on defining culture and cultural competence.  She said individuals view the world through a cultural lens and different thoughts and experiences are perceived differently depending on their culture.   She went on to explain that culture is dynamic and “many of us can evolve if we are open to it”.  She explained cultural competence as the ability to “communicate effectively with people that are different than ourselves” and stressed the importance of recognizing “cultural-based practices that dictate or organize us”.

Dr. Ryan commented that cultural competence is important to consider due to the changing of demographics in the US, the impact it can have on the sustainability of a business, and the critical role it plays in healthcare. The socio-cultural background of our clients can also have a large impact on individual members’ health values, beliefs, behaviors, quality of care and health outcomes.

Dr. Ryan stressed on the importance of understanding health disparities and the individuals that are directly impacted by these inequities, such as those with mental illness or low literacy rates.  Providing culturally competent cross-cultural care is key to combating these inequities and she provided effective frameworks that can be used to facilitate cross-cultural communication, such as the LEARN and BATHE models. She concluded with an explanation of the federal mandates that exist to address cultural competency, such as the CLAS Standards, ADA requirements and NCQA MultiCultural Standards.

Adapting Health Interventions for Improved Cultural Relevance

Cathy Meade, PhD, RN, FAAN

Cathy Meade, PhD, RN, FAAN

Cathy Meade began the session by discussing ways in which organizations can develop interventions that are tailored to the communities they serve.   In order to establish these interventions, Dr. Meade suggests pulling together different members of the community to gather their perspective on issues that surround the community.

Dr. Meade suggested interventions involve a “top down then bottom up” methodology.  This methodology implies that an evidence based curriculum is reviewed by the target population and then should be tailored to meet their needs.

To conclude the session, Dr. Meade gave an example from her field work of how utilization of all the components can lead to culturally relevant interventions.

Health Literacy 101: An Introduction to the Field

Michael Villaire, MSLM

Michael Villaire, MSLM

Michael Villaire gave an introduction to the field of health literacy. He began by defining health literacy. His favorite definition is the one from the 2008 Calgary Charter: “Health literacy allows the public and personnel working in all health-related contexts to find, understand, evaluate, communicate, and use information.” Villaire prefers this definition because “it puts the onus for health literacy on the provider, as well as the consumer.”

The healthcare system is bewildering to many people, Villaire said. He gave the example of the challenges people face in signing up for health insurance under the Affordable Care Act. Villaire talked about the components of health literacy: reading and writing, listening and verbal communication, numeracy, and self-efficacy. He gave some illustrations of how challenging numeracy is for many of us.

Villaire talked about the relationship between health literacy and culture. He noted that there is often a mismatch between provider demand and patient skill level, as well as between reading level and materials. And he discussed health literacy’s strong relationship with safety, quality, and health disparities. It can be hard to move an organization forward to health literacy. But “there are certain terms that will help you move forward with your goals. Two words: safety, quality,” Villaire said.

Examples were shared of how patients can be harmed when providers fail to give clear instructions. He put the burden on providers to improve their communication. “The fact that someone does not understand the way we choose to communicate is not their problem. It’s a barrier. It’s something we need to address,” Villaire said. “Health literacy is about dealing with the barriers.”

Villaire discussed health literacy myths and listed the barriers to health literacy. He also offered health literacy statistics and noted that people don’t like to admit they don’t read well because they are ashamed, therefore limited literacy is under-reported. He closed the session by explaining why health literacy matters and discussed the impact of low health literacy.

Integrating Health Literacy into Your Organization: Subtle Issues to Consider

From left to right: Jann Keenan, EdS, Janet Ohene-Frempong, MS

From left to right: Jann Keenan, EdS, Janet Ohene-Frempong, MS

Jann Keenan and Janet Ohene-Frempong explained how to integrate health literacy into your organization. They listed issues to consider along the way.

They noted that health literacy reform has worked in pharmaceutical companies, the insurance industry, state health departments, hospitals, and government agencies. They believe that this is “a golden age for organizational change”.

A health literate organization makes it easier for people to navigate, understand, and use information and services so they can take care of their health, the presenters said. They listed the Institute of Medicine’s implied action steps for becoming a health literate organization:

  1. Make health literacy integral to your mission, structure, and operations.
  2. Integrate health literacy into planning, evaluation measures, patient safety, and quality improvement.
  3. Prepare your workforce to be health literate and monitor your progress at doing so.
  4. Include populations served in the design, implementation, and evaluation of health information and services.
  5. Meet the needs of populations that have a range of health literacy skills, while avoiding stigmatization.
  6. Use health literacy strategies in interpersonal communication and confirm understanding at all points of contact.
  7. Provide easy access to health information and services and navigation assistance.
  8. Design and distributes print, audiovisual, and social media content that is easy to understand and act on.
  9. Address health literacy in high-risk situations, including care transitions and communications about medicines.
  10. Communicate clearly what health plans cover and what individuals will have to pay for services.

The presenters discussed some common roadblocks to integrating health literacy into an organization:

  • A lack of compassion and commitment
  • A lack of time and money
  • Legal and regulatory requirements
  • The need to hire, train, and retain staff
  • The need for industry specific guidelines
  • The challenge of including marginal readers
  • The challenges of health system complexity

They offered detailed strategies for how to navigate these roadblocks, based on the IOM’s guidelines.

Beyond Enrollment: Helping the Newly Insured be Part of the Solution

Kavita Patel, MD

Kavita Patel, MD

Dr. Kavita Patel was unable to attend the conference in person due to health problems, but joined the conference by Skype. She talked about problems with healthcare in the U.S. and how “one of the most common myths… is that the U.S. has the best healthcare in the world.” This may be true for some Americans, but compared to other countries, we are not getting good value for our healthcare dollars, she said. That’s why the Affordable Care Act (ACA) is so significant, but sometimes that gets lost in all the discussion about enrollment.

The ACA is bringing sweeping changes to all sectors of healthcare, impacting hospitals, makers of medical devices, health insurance companies, and employers. Although some aspects of the ACA have been delayed, like the employer mandate and applicant verification, many of these changes have already come to pass:

  • Expanded access to coverage by building on the existing healthcare system
  • More competitive and transparent healthcare markets
  • Reformed the health insurance market and hold insurers accountable
  • Simplified healthcare administration and reduction in waste, fraud, and abuse
  • Improved quality and delivery systems to lower costs
  • Focus on prevention and wellness

Dr. Patel talked about polling on the ACA. She noted that while many Americans don’t like “Obamacare,” some specific ACA provisions are very popular — such as getting rid of preexisting conditions and keeping 26-year-olds on their parents’ health insurance. “So there are some messaging problems,” she said.

She discussed how health literacy intersects with the ACA. She listed the Institute of Medicine’s attributes of a health literate organization and laid out a health literacy agenda. Dr. Patel illustrated how low health literacy is costly in both human and financial terms. “You can make a business case, a patient case, and a provider case for health literacy,” Dr. Patel said.

Dr. Patel listed questions every consumer and provider should ask about health insurance. They are based on a project called Let’s Ask 4: What are my choices for health insurance?, How do I get it?, How do I use it?, How much will it cost me? Dr. Patel closed with examples of health literate consumer guides.

Numeracy Requirements for Health Insurance Enrollment

Ellen Peters, PhD

Ellen Peters, PhD

Ellen Peters gave an introduction to numeracy. She also discussed how numeracy is relevant to the Affordable Care Act (ACA). Numbers instruct, inform, and give meaning to information about health plans, medicines, and treatments, Peters said.

But not all people can understand and use numbers effectively. Even highly educated people can be innumerate, she said. Less numerate people are more likely to be female, older, less educated, and poor. Plus, they are less likely to have health insurance, Peters said. Thus, the average numeracy skills in the ACA population will be lower than those of currently insured consumers. The newly insured will also have less knowledge and experience in healthcare settings, Peters said. “They may not know as well how to be a good patient — how to interact with doctors and nurses, how to record symptoms.”

Peters talked about numeracy skills that we learn in school. She also listed numeracy skills that we use to make decisions. We use these skills when we:

  • Seek information
  • Pay attention to numeric information
  • Ignore irrelevant information
  • Recall numeric information
  • Are sensitive to numeric information
  • Derive affective meaning from numeric information

Peters gave some examples of using numeracy. “Healthcare providers often underestimate how difficult these tasks are. And patients are often reluctant to admit that they don’t understand,” she said.

The way information is presented can reduce numeracy differences, Peters said. She offered strategies for providers to communicate with less numerate people:

  • Provide numeric information. “Numbers help whether you’re more numerate or less numerate,” she said.
  • Do the math for people.
  • Provide evaluative meaning, particularly when numeric information is unfamiliar. “If people don’t know how good or bad the number is, they’re not able to use the information,” Peters said. But take care when providing evaluative meaning, because it’s a big responsibility.
  • Draw attention to important information.
  • Set up appropriate systems to assist consumers and patients.

Communicating Clearly With Low Literacy Patients: A Skills Workshop

Julie McKinney, MS

Julie McKinney, MS

McKinney and Neuhauser moderated a panel discussion with adult literacy tutors and learners from Read Orange County, a local library program. The panel — tutors Barbara, Al and Fritzi, and learners Van and Jay, and Jay’s mother — shared their expertise for communicating health messages respectfully, clearly and effectively.

The co-hosts indicated that the best way to communicate is by interacting as a shared team – on equal footing, as partners who determine goals, barriers and what works well. Tutors have information about their learners before they meet, including an assessment of what the learners can and can’t do and what they want to accomplish. Tutors and learners then meet at a library or another public place for about an hour twice a week.

The tutors first establish short-term goals (perhaps reading a book) and long-term goals (e.g., getting a driver’s license). They establish a rapport and require learners to show comprehension (not yes or no). They explained that it’s important to use open-ended questions and to convey you’re there as a friend to help them. The tutors get to know their learners’ interests and family dynamics so they can relate to them, break down roadblocks and build confidence.  Each learner has strengths in other areas – not just challenges with reading and writing.

The co-hosts listed several sources for finding local literacy programs:

  • America’s Literacy Directory – lincs.ed.gov
  • Proliteracy – proliteracy.org
  • Ask your local library

At the end of the panel discussion, Jay, one of the learners, sang several bars of Louis Armstrong’s song – What a Wonderful World!

Health Insurance Literacy: Solutions from a Successful Model

From left to right: Ryan Barker, MSW, MPPA, Kelly Ferrara, Catina O’Leary, Ph.D.

From left to right: Ryan Barker, MSW, MPPA, Kelly Ferrara, Catina O’Leary, Ph.D.

Catina O’Leary, Kelly Ferrara, and Ryan Barker discussed the strengths and difficulties of the Cover Missouri Coalition and how they collaboratively reached a total of 152,335 enrollments.

The Coalition was established due to the recognition that state was not in full support of Affordable Care Act and as such the state and some county health departments could not participate in outreach and education for the Federal Marketplace.

Although the main goal of the Coalition is to “reduce the uninsured rate to less than 5% in the next 5 years” they believe that “it’s more than that”.  Their initiative seeks to “increase access to healthcare, preventative care, and create real change with real peoples’ lives”.  In order to accomplish this goal the coalition mentioned that using and understanding health insurance is a multistep process.  As such, the coalition worked with different organizations and groups that would help at each step to increase health literacy.  This multilayer approach included working with physicians on communication, translating material to be disseminated in outreach, and working with community members to ensure materials were culturally sensitive.

Some of the key ingredients to their success were having an active facilitator who positively and enthusiastically encouraged participation, developing a digital drop box to make material readily available, and face to face interaction, which was vital to outreach and engagement.

A Health Literacy Workshop to Engage Community Groups

From left to right: Stan Hudson, MA, Nick Butler, MA

From left to right: Stan Hudson, MA, Nick Butler, MA

Hudson and Butler talked about their experiences leading communication workshops for patients and providers. The workshops train patients on how to be better patients and train providers on how to be better providers. Patients can include people with a certain disease, seniors, new or expectant parents, and LGBT people. Providers can include students and practicing doctors and you can tailor your case to that particular group. The presenters offered some guidelines for holding a workshop. You’ll need partners, time, travel, and money. But it can be done inexpensively, they said.

Before the workshop, you may want to:

  • Coordinate and prepare the meeting
  • Recruit a group
  • Find out what their issues are, and choose an appropriate case
  • Recruit and train people to act in role-plays
  • Train a facilitator
  • Market and promote the workshop

During the workshop, you may want to:

  • Conduct a pre-workshop survey
  • Talk about health literacy
  • Encourage learners to share their stories
  • Conduct role-plays
  • Discuss in small groups
  • Debrief in large group
  • Conduct a post-workshop survey

After the workshop, you may want to:

  • Report on the process and forms
  • Submit completed surveys

The presenters showed public service announcements about being an active consumer. The PSAs show how consumers who are happy to ask questions in other contexts can be very quiet and passive in a doctor’s office. All of us are more likely to have low health literacy during times of stress and in unfamiliar contexts. That’s why we need universal precautions. The presenters have had positive results with their workshops. “In small-group sessions, countless times, I’ve seen the light bulb go on with the simulated doctor,” said Butler. “I think there’s a lot of opportunity within the Affordable Care Act (ACA) to fund some of these initiatives.”