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, Ed.S & Janet Ohene-Frempong, MS, IHA Strategic Partners

Jann Keenan and Janet Ohene-Frempong gave a daylong workshop on strategies for communicating effectively with constituents through both print and online materials. They used many samples created throughout their careers to illustrate what works and what doesn’t work. Ohene-Frempong stressed the health communication and health literacy must incorporate a reader-centered approach. This is the best way to engage, support, and motivate readers. They offered tips for how to implement this approach in both writing and designing materials in different media.

The presenters discussed how to write effective materials by offering tips on content, organization, and style. They also discussed effective design and page layout techniques to engage readers and increase understanding. If you aren’t designing your own materials, then it’s important to raise awareness in your designer about why design needs to be done a certain way. Keenan emphasized that an early buy-in from all partners in the creation of patient materials is key to creating health literate communication.

The presenters explained how to assess the readability of text and design and explored how to use readability tools and field-testing. They discussed how to revise text and design to improve readability. They also coached participants on how to plan a writing project. They encouraged attendees to be advocates for their readers. If there is crucial information you want to include, but limited space, the writer must fight to keep content that will benefit the end-user.

The workshop included two group exercises: a writing exercise and a revising exercise. The presenters led the group through the exercises step by step. The main take away from the session was that we must write for our readers and end-users. Being focused on the end-user is crucial to the creation of clear and effective communication.

User Centered Design for Audiences with Limited Literacy Skills: An Introduction to Research and Testing Methods for Print and Online Materials

Xanthi Scrimgeour, MHEd, MCHES

Xanthi Scrimgeour, MHEd, MCHES

Xanthi Scrimgeour, MHEd, MCHES & Stacy Robison, MHEd, MCHES, CommunicateHealth, Inc.

Xanthi Scrimgeour and Stacy Robison facilitated a pre-conference workshop titled, “User Centered Design for Audiences with Limited Literacy Skills:  An Introduction to Research and Testing Methods for Print and Online Materials.”

The definition of User Centered Design (UCD) was provided as “Involving end-users (your audience) in the design and development of a product, message, or campaign.”

Stacy Robison, MHEd, MCHES

Stacy Robison, MHEd, MCHES

The workshop focused on the following:

  • Steps to the User Centered Design process (Co-creation, Participatory design)
  • Methods in getting to know your audience (or clients) in order to involve them in serving as “co-creators” in designing key marketing tools to be used by actual clients
  • Methods to conduct user research and organizing information gathered
  • Testing Methods for getting feedback from your target audiences
  • How to involve participants with limited literacy
  • Ways to save time and money on user research and testing

The facilitators provided 5 reasons to involve your actual “audience” as part of the co-creation/participatory design:

  • Just because you think your material is awesome doesn’t mean that your audience has the same opinion.
  • You can waste a lot of time and money developing materials and products that your actual audience will not use.
  • Involving your current audience will allow you to assess whether or not your messages will be understood.
  • Target audience members will be empowered and invested in the success of your product.
  • It will make you a better communicator.

Both facilitators discussed the importance of talking directly to your audience (client, patient, etc.) to create “personas.”  Personas are created based on a mix of people.  It is based on actual research with your audience to prevent the persona from being a “stereotype” – and not necessarily related to people.  One can achieve creating this step by performing focus groups, one on one client interviews, collage exercises, etc.  It is important to also create a specialized group of individuals (recruits) to develop personas.

Our facilitators engaged attendees of the session in interactive exercises to further describe and understand the value of creating personas.

Best Practices for Health Insurance Outreach, Enrollment, Retention & Utilization: A Train-the-Trainer Session

Amy DeMarco, MPA

Amy DeMarco, MPA

Amy DeMarco, MPA, Institute for Healthcare Advancement

Amy DeMarco led this interactive train-the-trainer session on the OERU model (Outreach, Enrollment, Retention and Utilization) for coordinating health care access for the uninsured and newly insured. This model was originally created for the Healthy Families Program, also known as California’s State Children’s Health Plan. Best practices on how to reach and engage the uninsured were introduced in conjunction with experience-based guidelines on how to enroll consumers into health care coverage through a healthcare marketplace, like Covered California, California’s state-based healthcare exchange.

DeMarco stressed the importance of following up with clients and how getting them in for an appointment may require different techniques. She also shared tips on personalizing  documents for clients  such as highlighting keywords, writing the clients name, and underlining important information to help them retain and act on the information provided. Attendees were asked to share what works best for them and what has received a positive response from the client.

Difficult health care terms were explained in plain language. The presenter also ran through several common enrollment scenarios and asked participants to role play as the CEC and the client. Then these scenarios were discussed in the larger group so attendees could learn from others’ experiences.

Emphasis was placed on the Retention and Utilization portions of the trainings because there has been a great push by the marketplaces to increase enrollment, but little support provided to enrollers or healthcare workers to help these clients use their coverage and retain their insurance long term.  Suggestions for helping clients remember to pay their bill each month and renew their coverage each year were discussed. Reasons and solutions for why clients might not retain their coverage were also discussed.

Using the teach-back method was suggested to help clients understand their coverage and what they need to do to keep it. The Ask Me 3 technique was an audience suggestion on how to ensure that clients understood the health insurance information provided to them. This technique  helps enrollment counsellors identity the client’s main concern , develop next steps for the client,, and establish why it is important for them to take these necessary steps to get, keep and use their coverage.

The Utilization section kicked off with role-play scenarios where an audience member explained to a client how they could effectively navigate the healthcare system to use their coverage. The different types of care were discussed and the presenter explained in plain language terms the attendees could use with clients to explain when go to the ER, urgent care, and primary care provider (PCP) and how seeing their PCP first in non-emergency situations could save a client money.

Collaborative Approach to Testing Materials: A New Industry Paradigm

Left to Right: Kara Jacobson and Heather Turkoz

Left to Right: Kara Jacobson, MPH and Heather Turkoz, M.A.

Heather Turkoz, M.A., Merck & Kara Jacobson, MPH, Emory University

Heather Turkoz and Kara Jacobson used their experience to illustrate to other healthcare professionals how a collaborative approach to testing can create highly effective health communication material. Their collaboration is a case study on how a company, like Merck, can partner with a diverse set of stakeholders, like Emory University and Northwestern University, to improve its patient communication. In this case they partnered to improve Merck’s patient labelling process through evidence based market research facilitated by Emory. Their collaborative approach included the application of health literacy principles into a newly designed patient package insert and implementing new market research methodologies to solicit and incorporate feedback from respondents of all health literacy levels.

After implementing health literacy best practices into the patient package insert, research showed that the average comprehension scores were 93% across all subjects with no meaningful differences between those with limited health literacy and those with adequate health literacy. Turkoz and Jacobson provided new perspectives and insights on a model for building an effective partnership between industry and academia to affect real change and improvement in health literacy.

In order to develop patient labelling that was well understood and actionable, application of best practices from the field of health literacy was required. These methods are commonly used within the field, but not within the pharmaceutical industry. These included identifying and recruiting patients with limited health literacy into the research and refining the methodologies to assess comprehension of medication information. The presenters also emphasized the importance of including an iterative method to incorporate patient and caregiver feedback into the development process of patient communication. The recruitment and screening techniques for populations with limited health literacy were shared and can be applied by participants from other large organizations within the health industry. Furthermore, their testing methodologies can be used with a broad range of patients, inclusive of all health literacy levels. Lastly, they shared implications for future development of patient communications that go beyond the patient package insert.

How to Use the Book ‘What To Do When Your Child Gets Sick’: A Train-the-Trainer Session

Diana Gonzalez, MPH

Diana Gonzalez, MPH

Diana Peña, MPH, Institute for Healthcare Advancement

Diana Peña’s preconference session began with a brief introduction to the Institute for Healthcare Advancement and the production of their “What To Do” book series.  The book “What To Do When Your Child Gets Sick” was chosen for the training since it is the organization’s flagship book.  She then gave an introduction to the mock training with a discussion on how a trainer would prepare to administer the class. She mentioned strategies to increase the probability of a successful class such as providing childcare and sending reminders to participants.

The mock training was delivered as though Peña were facilitating training to consumers who would use the book at home with their families. The training began with a video created by the Kansas Head Start Association.  The movie gave expert insight on the effectiveness of the book as well as its utility for parents. Later participants were introduced to the easy to use format of the book and practiced using the book with real life scenarios.

Lastly the train-the-trainer model was delivered as though the participants in the session were trainers for the book.  Peña reviewed subject matters needed to deliver an effective session such as health literacy, culture, and adult learning.  She discussed the importance of understanding and teaching in a manner that acknowledges the health literacy levels of adults.  Participants were then given the opportunity to practice two techniques that acknowledge participant health literacy levels, teach back and plain language.  The remaining of the session focused on managing classroom situations such as too many question, limited time, and managing disagreements.

Discussion on managing classroom situations allowed participants to share experiences and knowledge as well as brainstorm new ideas.  The session ended with a wrap up activity that brought all ideas together.  Participants were to pick a section of the book and use plain language to describe this section to another participant.  Then participants checked to see how well they explained the section by using teach-back.  This was a great way for participants to practice with the book as well as practice newly learned skills.

Your Health Insurance – How It Works and How to Use It: A Train-the-Trainer Session

Amy DeMarco, MPA

Amy DeMarco, MPA

Amy DeMarco, MPA, Institute for Healthcare Advancement

This Train-the-Trainer session lead by Amy DeMarco walked attendees through the process of providing the “Your Health Insurance” training to current or potential clients. This training covered:

  1. What it means to have it
  2. What it is and how it works
  3. What it covers and what it may not cover
  4. How to use it to stay as healthy as possible
  5. How to keep it now that you have it

DeMarco introduced some scenarios clients may have faced if they were uninsured and how their new benefits can protect them from high hospital costs or putting off getting care. She then explained common health insurance terms in plain language and asked participants to share how they have explained these terms to clients.

The ten essential health benefits were explained as well as what a typical marketplace plan may not cover. Attendees shared their remedies for covering these gaps in coverage, like taking vision prescriptions to big box stores that can make glasses at a lower rate or adding on dental coverage outside of the marketplace with their new insurer. She shared instructions on where clients can get more information on their benefits, costs, and providers.

The presenter discussed 8 steps clients can take to stay healthy:

  1. Understand your health coverage.
  2. Know where to go for care when you are sick
  3. Find a provider.
  4. Make an appointment.
  5. Be prepared for the visit.
  6. Decide if the provider is right for you.
  7. Follow the health plan you and your doctor agreed on.
  8. Take the time to read about your prescription plans.

Lastly, 5 tips to helps consumers keep their health insurance were shared:

  1. Pay your premium(s) on time.
  2. Understand your medical bills and pay them on time.
  3. Tell your marketplace and  health insurer about any changes in your contact information.
  4. Tell your marketplace when you have a life change.
  5. Renew your coverage.

The session closed with feedback, scenarios, and examples from participants on what strategies they have employed to help clients understand and use their health coverage. Attendees also discussed the different barriers faced throughout the nation in their states and communities and how they have worked to help clients overcome these barriers.

Health Literacy 101: An Introduction to the Field

Michael Villaire, MSLM

Michael Villaire, MSLM

Michael Villaire, MSLM, Institute for Healthcare Advancement

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.

Risky Business: Lessons about Clarity from Crisis and Emergency Risk Communication

Cynthia Baur, Ph.D.

Cynthia Baur, Ph.D.

Cynthia Baur, Ph.D., Centers for Disease Control and Prevention (CDC)

Emergency risk communication is now an everyday part of life for many public health officials. However, scientists, providers, and politicians need to recognize that people not understanding their messages is a risk factor in and of itself. We need to remind our colleagues and managers that they need to make their messaging intuitive, understandable, and relative to their target population.

Emergency events can occur at any moment. Routine issues can also cause emergency events, such as the annual flu outbreak. Other issues, like the Ebola outbreak in Guinea do not seem to pose a risk to other regions, but the health workers returning to their home countries triggered emergency events. Saying that “close contact with bodily fluids puts you at high risk” is extremely difficult to understand and is not actionable for many people. “Bodily fluids” is not an intuitive term.

Crisis and Emergency Event Communication (CERC) training at http://emergency.cdc.gov/cerc/ can help you learn how to communicate effectively during emergencies. The Clear Communication Index is another great tool to identify the most intuitive and direct way to provide a message.

Baur’s main message is that communicating about risk during a crisis or emergency event requires extra attention to clarity.  Quantifying risk is very difficult and most people to do not identify with the current low, medium or high risk assessments. Zero risk is not possible and spokespeople may not always be able to give you the exact benefits, consequences, and tradeoffs because they are dealing with gradations of risk.

Specialized communication was initially created for targeted medical professionals who would be managing the Ebola outbreak or dealing with patients. However, as time progressed and diagnoses started to occur in the U.S., the messaging needed to expand to mass communication for multiple audiences.

Types of risk statements:

  • Threats or harm to an individual or group of people
  • Outcome of a threat or harm
  • Factors that make a threat or harm more likely (risk factors)
  • Likelihood that a threat or harm will happen

Spokespeople act as if everyone shares the same understanding of risk, but to be health literate we need to understand and tailor messaging to the understanding of risk possessed by the audience. The key characteristics of Crisis and Emergency Events that affect clarity are uncertainty, nature of risk, and timing.

Best Practices from Healthy People 2020 (healthypeople.gov) on what to include in a public health message:

  • What’s known
  • What’s not known
  • How or why
  • Action steps
  • Empathy
  • Accountability
  • Commitment

A routine risk that can affect a specific area or population is a food borne outbreak. These can become so routine that people think the risk is smaller than it is. It is up to spokespeople to ensure that the public understand the urgency. The CDC’s Flu Vaccine Campaign is an example of public health messaging that forms urgency in the face of routine risk.

An example of a novel risk and the need for clarity can be found in their Ebola: Getting to Zero campaign. Other emergency events include natural disasters where general messaging on preparation is important, but once they happen there needs to be clear and targeted messages for specific populations. However the key messages of who is affected and how they are affected and what they can do can be carried across different types of messaging.

Dr. Baur’s overarching lessons about clarity in crisis and emergency events are:

  • Anticipate and practice before an emergency strikes
  • Pre-test and prepare drafts
  • Assume emotions, and allow them to guide when and how provide information and what level of detail is required
  • Recognize that understanding of risk evolves and people’s initial reaction is not where they stay
  • Include action steps


Linking Research and Practice: Strategies for a More Collaborative Health Literacy Community

Linda Neuhauser, DrPH, MPH

Linda Neuhauser, DrPH, MPH

Linda Neuhauser, DrPH, MPH, UC Berkeley School of Public Health

In this presentation, Dr. Neuhauser discussed how the gap between research and practice impacts the success of health literacy initiatives, and offered some strategies for linking the two, as well as examples of successes in this area.

Dr. Neuhauser began by sharing her early experiences trying to give advice to patients. Nobody listened to her science-based advice because they couldn’t relate to it. Her conclusion was that, while we as healthcare providers have messages to send, people have lives to live, and we have to find a way to connect our messages to their lives.

She told the story of how a vaccination program in the West African nation of Mauritania had failed for 20 years. Dr. Neuhauser was sent as part of a medical research team to figure out why. They toured the country, visited villages, talked to the people. Their process was based in design science theory, which focuses on problem solving rather than theory testing. The team was able to solve many of the problems inherent in the program by learning about how the people actually lived and what was important to them.

Finally only one problem remained, how to keep the vaccines cold in the desert heat. It turned out that the camel drivers had the answer: There was a nationwide network of refrigerators for camel vaccines that could easily be used for storing human vaccines as well. The resulting new vaccination program ultimately reached 85% of the population. Dr. Neuhauser’s take-away: Participatory design is key to health programs, and communication is the glue that holds a program together.

She then surveyed the audience and noted that no one present felt that their organization had a high level of adoption of health literacy practices. Most felt that their organization still had a very low level of adoption. This informal survey was representative, according to Dr. Neuhauser: Only 1% of all health literacy research has been translated into action. It has taken 17 years for 14% of the relevant research to make its way into clinical practice; and it takes even longer for these practices to make an impact on the community.

Dr. Neuhauser proposed a new model that differs from the traditional NIH Model of Research Translation, which relies on research and clinical trials for gathering information. Her newer model has researchers working together with practitioners and communities to co-design and evaluate programs.

Dr. Neuhauser then laid out some strategies for putting the newer research-to-practice model in action:

  1. Set up a research-practice unit in your organization. Such a unit needs researchers that are committed to action as well as practitioners that value evidence. It also needs health literacy and communication experts–and perseverance!
  2. Use participatory design. Focus on solving problems rather than testing theories. Test the design on users. This is an iterative process, one that was used by the developers of the iPhone and tablets. (As few as six (6) members of the relevant user group can help identify major issues that need to be resolved.)
  3. Get involved with policy change in your organization, in your community, and through legislation.

She then went on to give a few examples of successful programs built using this approach, including the California First 5 Kit for New Parents and a wellness program for migrant workers in China. Dr. Neuhauser’s work on these and other programs led her to this conclusion: One of the biggest barriers to health communication is that the audience is not motivated to read the information they get. Involving them in the design process helps bring down this barrier.

In closing, Dr. Neuhauser addressed the perpetual question of how to get buy-in from one’s organization for participatory design. Her advice: Nobody likes to fail. Find a [program] failure in your organization and use it as a reason to try a new approach.
Website: HealthResearchForAction.org


Session A: Creating a Needs-Based Health Literacy Initiative

From left to right: Stanton Hudson, MA, and Nick Butler, MA

From left to right: Stanton Hudson, MA, and Nick Butler, MA

Stanton Hudson, MA, & Nick Butler, MA, Center for Health Policy, University of Missouri

Stan Hudson and Nick Butler shared their experiences of working with two very different cities to establish a needs-based health literacy initiative.  Hudson and Butler reviewed components to a healthy literacy initiative including being able to identify and engage skill sets around health literacy and competencies, develop strategic partnerships, monitoring, generating feedback, sustainment through implementation science and having health literacy networks.

Hudson and Butler believe that essential tasks and components for a successful health literacy initiative include selecting steering committee members, participating in community outreach and engagement, organizing kick-off events and developing a request for proposal (RFP).  They also expressed the importance of phasing the initiative to ensure tasks are focused for the timely completion of objectives.  The incorporation of the following phases were part of their initiative in both cities: application procedures, review protocols, and selection criteria.

Hudson and Butler discussed their experience and key activities that took place when developing their initiative. It is important to note that although the initiative was conducted in two different cities the same key activities were completed.  Key activities conducted were a needs assessment, resource inventory, curriculum development, partnership development, demo projects and technical assistance.