Monday, December 20, 2010

Health Literacy: taking a closer look at a central strategy

Who would argue against plain language and simple language?
Nike's "Just Do it" 

"If you see something, say something." NYC MTA
"No Smoking"

Or, would they?

Is it possible that the compact to create clear and simple health information has over-promised - not lived up to its billing? What if the complexity of health information in the first half of the 21st century requires more than simple representations of science, medicine and decision-making? What if one could demonstrate that while the intentions to simplify are good, many of the executions are bad? What if simplification has yielded a public health communication by subtraction, the consequences of which are that we are unwittingly perpetuating limited access to the complex and nuanced information necessary for patients and publics to make informed decisions about health. And added to this, what if we could demonstrate that un-interrogated surface level simplification of information is also likely to perpetuate an unequal access to society’s larger information commons. This essay focuses on what rules of clear and simple are the right ones to produce a readable usable text that will improve comprehension and engagement with health information. This essay explores the question and proposes two core principles of sociolinguistics that can be useful in recalibrating the role of simplifying health language. Think of it as a piece of architectural criticism.

Here is my new article "The Simplicity Complex: Exploring Simplified Health Messages in a Complex World" appearing in Health Promotion International.
Link to abstract ijkey=flV5FbIG1aDft9c&keytype=ref

Thursday, December 16, 2010

The Joy of Stats - BBC

This is just one of the truly wonderful segments in the BBC series that is tackling the public's general lack of interest and skill with data.  Swedish Professor of International Health, Hans Rosling, with the help of some wonderful techno-graphics, makes so much more than numeracy graspable and revelatory.  Fun but deadly serious.

Unfortunately most of the BBC series is not available online in the US  ( if someone does know of a link, please let us know).  But one segment is on youtube.

I believe this is the kind of "story" we should be making fundamental to reaching our public and advancing health literacy.

Tuesday, October 19, 2010

Houston We Seem To Have a Problem

It’s hard to find anyone who would argue against keeping things “plain and simple.”  
Or would they?

Is it possible that the imperative to create simple health information has over-promised - hasn’t lived up to its billing? What if the complexity of health, science and technology information in the first half of the 21st century requires more than simple simplicity. 

Think back to swine flu
November 2009 - we were awash in breaking news, and precautionary recommendations - “Sneeze into your sleeve; wash hands often, stay home if you’re sick”.

Yet when all was said and done, only 35% of parents chose to have their children vaccinated.

Huston - we have a problem.
Why didn’t simple messages communicate and convince people to take action?

December  2009 - I’m loitering, with intent, outside a Harlem NY pharmacy chain store, as I and my students often do,  hoping someone will stop and talk about swine flu.

One does, a young woman. I ask,  “Why are experts in the city recommending sneeze into our sleeve?
            She responds, almost indignant, “For the environment.…You save the             paper….”
An elderly man stops to explain to me that he’s fighting the approaching virus thus;
            “Well, gotta see what it winds up being. Right now I’m just using that Purell. No                         more soap and water for me.”

Ah - is this magical thinking?  
Well no - it’s health literacy at work. 

I’ve been interviewing patients and consumers for over 30 years. Early on it struck me that my hardest and most exhilarating task as a linguist was to listen and try to figure out how people were making meaning of health, science, the world, their lives. 

So, in front of the pharmacy, I wound up interrogating myself. What is this person saying and what could it mean about what they understand and use to make choices? What could it mean about their health literacy.

While I didn’t thoroughly study a representative sample of New Yorkers, most people had heard the 3 hygiene messages. But, when I scratched the surface of their understanding of H1N1, things got murky fast.
  • What’s the difference between a virus and a bacteria?
  • What does it mean that H1N1 is a “new, ‘novel” virus?
  • What do vaccines do to protect us and why is it risky to let children “naturally” develop immunity during a pandemic

These more complex concepts and information did not make it into the popular messaging about H1N1.  But in order to weigh risks and benefits of vaccination and other precautionary behaviors, the health literate person has some facility with these more complex issues and uses them to make informed decisions.

I’ll conclude with 3 short propositions:
1. Let’s entertain the idea that simplifying health messages is often necessary but hardly ever sufficient. It should not be our primary tactic - the default tactic. 

2. Much simplified information results in staccato-like language that create yawning inferential gaps most people simply can’t fill.

3. If we agree that health literacy and health and social equity are related, the singular focus on simplifying, simplifying, simplifying has backgrounded or completely deleted out more complicated and nuanced concepts and information people look for and use.

I believe if we endorsed a change of focus about health literacy and people we would find ourselves talking less about what patients and consumers can’t understand and do, and turn our attention to figuring out what they do have and are using to make meaning and decisions every day.

This post also appears this week at

Thursday, October 14, 2010

Free Web Lecture on "Creating An Educated Citizen In Public Health" Free Web Lecture on "Creating An Educated Citizen In Public Health"

Description: In recent years, public health has become more commonplace in undergraduate education as the demand for a workforce with training in public health has grown and as students' interest in an integrated view of health has increased. Join Erin DeFries Bouldin as she discusses some of the efforts by the Association of American Colleges and Universities (AAC&U), the Association of Schools of Public Health (ASPH), and others to produce an educated citizen, one who is aware of public health issues, is engaged in his community, and possesses a global view of health. She will also provide specific examples of how to deliver public health content in the classroom that are applicable for instructors regardless of their field of expertise.

Presenter: Erin DeFries Bouldin, University of Florida

Date: 26 Oct 2010

Time: 4:00pm (Eastern)

Event Type: Guest Lecture

Duration: 1 hour

Sunday, September 19, 2010

Flu by Association - more from Christakis and Fowler

Great new research by Nicholas Christakis and James Fowler - the social network experts.  This time they've turned their attention to how people in social networks are at greater risk for getting the flu (Christakis & Fowler paper and their book Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives.  Jonah Lehrer has written about their work at Wired - Jonah Lehrer.
We all know that there are compelling reasons to be parts of networks, and large ones - sharing information, support, mobilization, etc.  the authors reveal a network paradox. But in this case, what the researchers show is that if a nasty germ is spreading around you're better off on the edge of a network. 
What's even more interesting than the concept is how the researchers actually operationalized the ides.
Christakis and Folwer followed 740 studets for 120 days.  Then compared the group of people who were names as friends to the group of people who were not.  Lo and behold those named as friends wound up being significantly more central in the network. And when they looks at who got the flu they found that these named friends got the flu about 14 days ahead of everyone else.
Some implications of this exciting research are that we could start predicting the course of an outbreak by monitoring networks.
But I'm also excited about the idea of social networks to spread health information and behavior change. Sort of like crossing Gladwell's "Tipping Point" with Christakis & Fowler's outbreak model.

Tuesday, August 10, 2010

(posted on The Health and Literacy Discussion List today 8/10/10)

Readability - a Catch 22
As we’ve been posting about the requirement to use x or y grade reading level, I’ve been thinking about how these regulations are really unintentionally sidetracking us from focusing on two important parts of reading comprehension:
1) what really makes  text/or message hard - often the concepts, not the word or sentence length; and
2) what type of writing will actually prove to be more able to adequately inform people and advance their health literacy

In the field of health literacy word and sentence length have been what we use - through applying readability formulas.  But readability formulas were not meant to drive regulation and policy. Way back in 1974,  Flesch, a developer of the Flesch-Kincaid, stated that he hoped users “won’t take the formula too seriously and won’t expect from it more than a rough estimate.”

What Flesch and others recognized is that short words are not always easy to understand and ong sentences aren’t always hard to understand.  The word “waive” as in “We will waive your premium” counts exactly the same on a Flesch test as “we,” “will,” and “your” (Redish & Seizer, 1985, p. 4). People in readability back in the 70s and 80s understood that reading is much more complex than processing rows of words and sentences. It’s why most textbook publishers don’t use readability scores anymore.

When we’re required to write to meet grade level/ readability criteria we’re caught in a Catch-22.  And we often wind up gaming the system - artificially dividing sentences and using sentence fragments (Ancker, 2004; Redish & Seizer, 1985, p. 4).  So if we ad the very words or sentences that would make the text really more comprehensible ( understandable) we wind up unhappily increasing the readability score of the material.  And the regulators don’t like that, so we write what scores better - often short sentences, without much cohesion, seldom introducing the vocabulary and concepts people need to truly understand, learn and use health information.

Jessica Ancker (2004) demonstrates this with the clever example:  “Be prepared to die next month,”  scores lower (easier-to-read) than “Call for an appointment next month” because the words in the latter are shorter.

Often the “simplified” text looks simpler, but when tested is not more understandable, and often more difficult to understand has been amply demonstrated (Charrow & Charrow, 1979; Davison et al., 1980; Duffy & Kabance, 1982; McNamara, Kintsch, Butler-Songer, & Kintsch, 1996; Kintsch, 1994). And, the Institute of Medicine (IOM) report, “Health Literacy: A Prescription to End Confusion” calls for researchers and practitioners to move beyond reading level to find newer solutions to low health literacy (Nielsen-Bohlman et al., 2004).

I call this situation The Simplicity Complex.
Anybody see any solutions?

(some references mentioned above)
Ancker, J. (2004). Developing the informed consent form: A review of the readability  literature and an experiment. American Medical Writers Association Journal(19), 97-100.
Charrow, R. P., & Charrow, V. R. (1979). Making legal language understandable: A psycholinguistic study of jury instructions. Columbia Law Review, 79, 1306-1374.
Duffy, T. M., & Kabance, P. (1982). Testing a readable writing approach to text revision. Journal of Educational Psychology, 74, 533-548.
McNamara, D. S., Kintsch, E., Butler-Songer, N., & Kintsch, W. (1996). Are good texts always better? Interactions of text coherence, background knowledge, and levels of understanding in learning from text. Cognition and Instruction, 14, 1-43.
Kintsch, W. (1994). Text comprehension, memory, and learning. American Psychologist , 49, 294-303.
Redish, J. C., & Seizer, J. (1985). The place of readability formulas in technical      communication. Technical Communication, 32(4), 46-52.

Thursday, July 1, 2010

What do Silly Bandz have that public health doesn't?

If you have a young kid, or even spotted one recently, chances are they are bedecked in squiggly plastic braceletes and necklaces - Silly Bandz!
 A small Toledo company is growing faster than it can keep up. Silly Bandz are all the craze,
"Roughly about a year ago, it really started to take off virally with the kids throughout different pockets of the United States. And the rest is history," said company president Robert John Croak. "It's insane."  The website gets over 11 million hits in one day!

The Silly Bandz craze reminds me of how malleable we humans can be and, as Dan Ariely says, how predictably irrational we are in our daily lives (Predictably Irrational, Harper Collins, 2008).   A human trait that we haven’t been able to capitalize on in most of our efforts to influence and “change” public health behaviors.

In The Tipping Point ( Little, Brown, 200) Malcolm Gladwell writes about an intriguing human phenomenon - the almost magical point at which a behavior among a small group becomes a trend, and sometimes an epidemic. For example, the resurgence in popularity of the almost dead shoe brand, Hush Puppies, - starting with kids buying them in resale shops in the Village, and ultimately becoming hip in Manhattan's bars and clubs in the mid 90s; or the drastic change in ideation about among youth on the island of Micronesia over the past 30 years - it now being viewed as a statement of their spirit of experimentation and rebellion.

It's not a new question, but I've been thinking about it again as I work on an obesity project here in NYC - How do we put this daily human phenomenon to work in public health?

We need to be using what commercial and social marketers have known for decades - convince people, rather covertly, to take their cues from the healthier role models, thought leaders and behaviors around them. 
 If the messenger is as important as the message, who should be delivering messages about healthy lifestyle, in what voice?  What would it take to instigate a word-of-mouth, "The red coats are coming" style epidemic of healthy eating and activity.  
Clearly the top-down, expert driven messages about the risks of overweight and obesity, how to count calories and how much to exercise, have not worked. 

Thursday, March 11, 2010

Ask Me 3 and Halloween

 After reviewing some of my old notes way back when Ask Me 3 was first being designed, the gaping hole in its  underlying premise became clear to me again.

The program is based on thinking that if you have patients model and mimic questions to ask the doctor, they will actually wind up using that specific verbal strategy.

The most clear evidence that this works is in contexts like Halloween.
Little kids, holding the hand of a parent, are coached endlessly,
say....."Tick or Treat"

say   "Thank you"

Surely we can do better.

Tuesday, March 9, 2010

Ask Me 3 fails to live up to its billing

In a recently published article ( Annals of Family Medicine) evaluating whether the much-touted ASK ME 3 Program really does improve patients' abilities to ask 3 important questions of their doctor, the study findings were disappointing.  I and many colleagues have been skeptical about the premise of AM3 over the years, and none of us are suprised about these findings.

The study found that patients in the program were no more likely to ask questions than a non-program population of patients. ( (Annals of Family Medicine 8:151-159 (2010   Annals of Family Medicine, Inc.)

The authors conclude that there is "no evidence that the  AM3 intervention results in patients asking their physicians a greater number of questions or more specific questions. The intervention did not improve adherence to treatment as we defined it, a finding consistent with previous studies that used similar, simple communication interventions"

The thinking behind Ask Me 3
The argument or conceptual model behind the Ask Me 3 program is that if patients ask good questions they will get better information and that will lead to better adherence to treatment recommendations.

Yet again, the authors suggest the predictable do-over with a less health literate population.
In trying to explain the failure of AM3 in their study, the authors state, "It is possible that AM3 might be more effective among patients who have lower health literacy skills."

I am concerned that the subtext here  goes something like this
- well maybe more educated, more health literate people don't need to practice asking specific questions of their physicians, but less educated, less health literate ( and perhaps less literate) people would benefit from this intervention. 

It's just a small, sidewise step to saying,
- if you're educated, learning to mimic questions and recite them back, parrot-like is probably not going to go over very well, but let's try it on the less educated. 

You see just about the same intimating in the conclusion of a 2009 RWJ funded study looking at the failure of the "clear and simple" Target prescription bottle labels to show any marked improvement in medication taking ( . In the Target case the authors concluded, "The label may have been more effective in improving understanding15 and stimulating adherence in Medicaid beneficiaries or the uninsured, who often exhibit lower health literacy, and our study did not evaluate these populations."
Shrank, et al., (2009) "Can Improved Prescription Medication Labeling Influence Adherence to Chronic Medications? An Evaluation of the Target Pharmacy Label" J Gen Intern Med

Neither group of authors in these two studies feels the need to explain why they're more optimistic for their programs when it comes to less educated or less literate, or even poor and uninsured people. 

Is it possible that what's passing for a coda on study re-design runs dangerously close to keeping alive old, hard to-die-biases and prejudices? 


Friday, January 29, 2010

The Mixed Metaphors of Genomics

Of all the language used to discuss medical topics,  I've found that the language of genomics is most embedded with metaphors.  I think this example takes the cake! 

"Crash-Test Reveals DNA Traffic Control
Enzymes that copy DNA don’t travel on a lonely highway, but instead ply their trade on crowded interstates. Researchers have discovered that when those DNA-copying machines run head-on into oncoming traffic, they kick the obstacles out of their way. The finding reveals new details about the “rules of the road” that help ensure that cells make accurate copies of their genetic material."

HHMI Investigator: Michael E. O’Donnell, Ph.D., The Rockefeller University
Research published January 29, 2010, in ScienceFor the full news story, please go to