Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, Founder of Health Literacy Month and your host of Health Literacy Out Loud. In these podcasts, you get to listen in on my conversations with some pretty amazing people. You will hear what health literacy is, why it matters and ways we all can help improve health understanding. Beyond learning what to do and why to do it, I hope that the people you meet and listen to inspire you, as they inspire me, to make a health literacy difference.

Today, I’m talking with Dr. Karen Schriver who is president of KSA Communication Design and Research — a consulting firm based in Pittsburgh, Pennsylvania. Prior to this, Dr. Schriver was Professor of Rhetoric and Information Design at Carnegie Mellon University where she co-directed graduate programs in professional writing and document design.

Dr. Schriver’s first book Dynamics in Document Design: Creating Text for Readers is now in its ninth printing. It won a national book award and is considered an essential text in its field. Matter of fact, this book was how I first heard of and got to know Dr. Schriver. I would go to her book whenever I had a plain language problem. Sure enough, the answer was almost always there. One sentence from this book stays with me even today. It reads, “Whether we call our audience readers, users, customers or stakeholders, they all want to know the same thing — to feel that someone has taken the time to speak clearly, knowledgeably and honestly to them.”

To me, that sentence conveys the essence of health literacy. Welcome to Health Literacy Out Loud, Dr. Schriver.

Dr. Karen Schriver: Thank you, Helen. It’s a pleasure to be here and I’m really happy to talk with you today.

Helen Osborne: How does good document design and all the principles that you’re talking about make readers feel respected and valued?

Karen Schriver: Readers can feel respected and valued when two things happen. One, when they understand the text. When they actually “get” whatever is being said via words and graphics. The second is when they feel as though the text itself responds to them emotionally. People really feel both are important when they are reading and understanding.

When people look at a text that is confusing, they don’t feel respected because they feel as though they’re not being talked to, just being talked at. An example is a pamphlet with difficult words, complicated sentences, or paragraphs that go on and on and on. These visual and verbal problems can be very confusing and troubling for patients.

A second kind of problem that text and graphics can create is an emotional one — when the person looks at a document or a Website and feels talked down to or insulted or even frightened by what they see. Good information design considers the reader’s likely emotional response to text and graphics. We know from years of research that reading isn’t just an intellectual cognitive activity. It’s an emotional activity as well.

Let me give you an example. A few years ago, I went to get a mammogram after having the feeling that I might have detected a lump in one of my breasts. In the doctor’s waiting room I was given a form to fill out. The waiting room was full of men who were waiting for their wives. I started filling out this form. At the beginning there was the usual name and address kind of thing. And then I came to this question about my breasts. There were two simple black circle line drawings intended to be breasts. But the strange thing was that the circles had been dissected into eight sections, so it looked like a grapefruit. And I was supposed to put an X on the section of the breast where I thought where the lump was.

I’m looking at this and was immediately horrified by the picture. I was thinking, “Oh my gosh, they might cut a wedge out of me like this picture.” And then I saw this guy looking over my shoulder and I felt really panicked and wanted to leave. At that point, I just put down the clipboard, sat quietly and didn’t fill out the form. I thought it would be better if I said nothing because then the doctors will have to find it on their own and I wouldn’t be part of my own demise. Now you could say see I overreacted to just to a simple line drawing. But I think when it comes to health that many of us panic over any indication that we might need surgery.

Helen Osborne: I’d be interested in taking this step by step, talking about the three components: the visual part, the verbal part and the affective or feelings part.

Karen Schriver: Yes.

Helen Osborne: I wonder if we could take those one by one. You’ve already given great illustrations of what goes wrong. How could we make this better in documents we are writing?

Do you want to start with the visuals since you’re talking about a breast that looks like a section of grapefruit? Obviously, that didn’t work. How can we use the visual parts of a document to help people feel more respected and valued and also understand?

Karen Schriver: It’s hard to specify without looking at a concrete case because it’s difficult to generalize. But there are some things that people can do, whether or not they have training in visual design. My first recommendation is to collect examples of the type of documents or Websites similar to what you are working on. Be a kind of detective — a visual detective — and try to notice what works and what doesn’t work.

Now, if possible, find examples that have been usability tested. People who did the testing could tell you what worked and what didn’t.

Helen Osborne: And by usability testing, you mean that this document was tested with actual readers or users of the material?

Karen Schriver: That’s right. Actually having someone sit down with the material and go through it looking at all the words and pictures and interpreting them together.

One of the things about information design is that the words and the images are not necessarily separate. We see them separately but when we look at a document we’re inspecting the whole thing. Often because pictures grab us faster, our eyes are attracted there first. Typically, we’ll look at the pictures and then the captions and then scan for headings and subheadings. After that, if those things seem interesting and as though they’re oriented towards us, then we might get into the text and start reading.

Helen Osborne: So it’s not that people start at the top and go down in a logical order — people look all over a document and find where they want to start.

Karen Schriver: That’s right. Writers often make the assumption that people begin with the first word and then just keep reading. As designers, we tend to think that people start at the top left and just move left to right and down the page. But research shows that isn’t what happens.

People are attracted primarily to contrast, which is one of the key visual principles that has been studied by researchers again and again. Contrast is created by differences in light and dark, thick and thin, big and small. For example, headings that are bolder than the text, pictures that are big in relation to small pictures. And readers will scan the text for those things that jump out at them. If everything is the same hue or the same shade of grey, then nothing will jump out. That sort of disempowers people and they don’t want to keep going.

Helen Osborne: You were talking about looking at what works and what doesn’t work and now you’re talking about the contrast. Is this a category of something that does work? Do we want to have contrast in our documents?

Karen Schriver: Yes, we do. We want to have contrast in the typography — the headings and the sub headings should be darker than the body text. We want to have contrast in our line lengths so that important things have shorter line lengths and captions, for example, might have longer line lengths. If we have opportunities for using color, we would want to save color for parts of the document or Website that you really want people to focus on. They’ve done studies that even tiny babies can detect differences between light and dark, thick and thin, big to small, short to long. Our eyes seemed to be hard-wired to detect dissimilarities. One key principle of information design is to capitalize on that natural attraction to contrast and build that into your document.

Helen Osborne: Is there a time when there is too much contrast? I’m picturing a document like a quilt made with different scraps of fabric. It can have so many colors and so many designs that I’m not sure which I like the best. In a document trying to teach information, could that be distracting or does this enhance understanding?

Karen Schriver: Well, a document is unlike a quilt in that the kind of contrast that we want is for similar information to be signaled in similar ways. And so, if we look at a quilt, each square is independent and bound together such that the whole view together is an interesting tapestry. But when we look at a document, we don’t want to see, for example, some headings in one font and one level of boldness and some headings in another font and a different level of boldness. We wouldn’t want to see some procedures formatted as steps using numbers, while other procedures are formatted as itemized lists, and yet other procedures formatted as paragraphs. That would be chaotic contrast and confusing to the reader.

What we want to see is the designer or writer step back from the text and say, “what are the families of information here?” “What goes with what?” Another principal of document design is grouping. What we want is to create grouped families of content so that all procedures are formatted in exactly the same way. For example, all general overview information might have a longer line length, might have a lighter hue of text and serves as a kind of umbrella over the text so that the reader gets the sense, “I see this is the big picture.”

Helen Osborne: Will readers respond to that visually? Will this bring them into the document and make them want to read it and get into more of the body of information?

Karen Schriver: Yes, it will. When they see these cues that lead them into the text, very often these high contrast areas will be what they focus on most. And if those few initial things look interesting, then people tend to go back into the text and look more. Now, if when they actually start reading and find that the text is not responsive to their needs or perhaps condescending or irritating, then they shut down. It doesn’t matter how clear the writing is or how good the design is. If the content is not there in terms of what the reader expects to see and what they need, then the reader will eventually stop. We really need to try and do everything we can first to get the reader to read and second to keep them reading.

A few years ago, my colleagues and I did a study of how teenagers interpret drug prevention literature. These are brochures and pamphlets intended to discourage children and teenagers from taking drugs. We wanted to find out whether brochures and pamphlets in this genre were effective. We collected over 100 brochures and handouts from national and local drug prevention agencies in my area (Pennsylvania, West Virginia, Ohio). And a lot of these were funded by taxpayer dollars, so they were important documents with good money spent on them.

We asked over 300 students to take part in this study. They were from inner city schools and suburban schools, a wide range. We asked them to look at these brochures and pamphlets and to participate in focus groups, surveys and interviews. We used a method called “think-aloud” protocol where students read aloud and just comment on the words and the graphics and pictures as they go along.

Helen Osborne: What did the students tell you?

Karen Schriver: They told us a whole lot about what worked and what didn’t. I could tell you about one brochure called “Snappy Answers.” It was a one-page flyer and supposed to go to preteens to early teens. At the top of the pamphlet was the heading “Here are some snappy answers to the question. Want some alcohol or other drugs?” This pamphlet then went on to list 10 or 11 answers that teens could say back if someone said this question to them. Some of the answers were things like “No, thanks, I’d rather walk my pet python.” Or “No, thanks, I’m all American” or “I’ll stick to milk.” Or “I’d rather not, I’m too special.”

Now, you can imagine when students started to read this pamphlet they started laughing and making fun of it. They said first off, no one would ask the question, “Would you like some alcohol or other drugs?” Just saying both of those things in the same question seemed lame as they put it. This is what we were talking about earlier — you can get them in with the catchy heading although they didn’t respond well to it. The items for them to say back were formatted as a bulleted list and so one would think, “Well, that would draw them into the text.” It did, but just once. When students saw the answers, they started saying things like, “Oh, that must have been written by some weird hippy who thinks he’s cool, but he’s not.” It really had no relevance. And it seemed to them like the author was condescending and talking down to them.

When we looked across these brochures, we looked at two things. Did they get it? Did they understand it? That’s the cognitive part. And then, how did they feel about it? Were they persuaded by it? We found that students understood the brochures about 80 percent of the time. They could say, “Well, I know how many seconds it takes for crack cocaine to enter the bloodstream.” From a cognitive point of view, they got it. But when they actually thought about it and we asked, “Were you persuaded by that?” They would say, “No, it was a joke.” In over half of the cases where they got 80 percent correct on comprehension, the students thought the message was not persuasive and they would not be influenced by the brochure at all.

Helen Osborne: Since you are the “guru of design,” I want to ask you another age-old question: Do you recommend using serif or sans-serif fonts?

Karen Schriver: That question is asked quite a lot. Well, here is what the research says: fonts look a little bit different, depending on whether you’re presenting your information on paper or on the Web. If you’re designing on paper, it’s usually a good idea to present your body text using a serif font.

Helen Osborne: And serif is like Times New Roman?

Karen Schriver: That’s right, Times New Roman has extra details on what are called “ascenders” and “descenders.” They have little curly-q’s on the edge of the a’s, p’s, h’s — that kind of thing. Sans-serif does not. It’s a very clean line, the kind of line you would see on a stop sign.

Helen Osborne: So on paper, the body text should be serif?

Karen Schriver: Yes, on paper the body text should be serif roughly between 11 points and 13 points depending on who the reader is. If it’s an older reader, you’re going to want to pump that up to even 14, 15, 16 points, depending on what we call the “x height.” The size of the height of the small letters is really what matters in terms of legibility. If you start noticing that a’s and o’s and e’s are closing up on you — even slightly when you’re squinting — then you know you need to pump up the size of the body text a little bit. In contrast, you want to make your headings sans-serif and bold. Typically we want to have headings at least two shades bolder than our body text.

Moving to the Web is a different story. There, serifs sometimes tend to scintillate because light is coming from behind the screen and projecting towards you. And so in designing for the Web, generally speaking it’s a good idea to go with sans-serif fonts because they are cleaner and much easier to see with light projecting behind them. But I have to say that both serif and san-serif faces have been found to be equally legible.

One of the funny things is that the font that people really want to see depends on the country they are from. In the U.S. and Canada for example, we have grown up on a tradition of textbooks all created in serif. Think back to books you read as a little child, most of them were printed in serif faces — New Century Schoolbook, Garamond, Times, Palatino, a variety of serif faces. But Europe has a completely different tradition. And so, if you are designing something that must cross cultures you really need to think about what the tradition is. Again it’s not just an issue of cognition; it’s an issue of preference. Some people don’t want to read stuff that isn’t like what they’re used to. That may not be fair but that’s how it is.

Helen Osborne: Thank you for sharing that. As you’re explaining that I’m thinking we could just have a whole podcast just on type. I’m just curious if non-romance languages even have serif sans-serif. This talk of the cultural aspects is fascinating and I thank you so much for sharing it.

I know it’s also a challenge for listeners to just have auditory in this podcast. Is there a way to learn more about these topics?

Karen Schriver: Yes, there are several ways. One is to search the Web for the term “information design.” There are many Websites related to information design and I will be happy to provide some links.

Helen Osborne: And we’ll also have those links on the Health Literacy Out Loud podcast page.

Karen Schriver: Sounds great. There are also books that can help train your visual eye. I was saying you should look at a lot of examples. If you look at expert designers, they are really excited about looking at texts and taking mental pictures of those texts — they remember the good parts and the bad parts. That’s the kind of thing we want to build up over time. There are good books out there to help you do that.

Helen Osborne: We want to include a link to your book as well — I know how much it has helped in my plain language practice. Many of our listeners are content experts who know their topic but are not necessarily experts about design.

Good design is not necessarily intuitive but rather something we need to learn. Thank you for giving us some heads-ups and tips about doing just that. And for resources to start getting a sense of what works and what doesn’t. I thank you so much for sharing with us on this podcast, Karen.

Karen Schriver: You’re welcome and thank you for doing this podcast series. It’s just been fabulous. I’ve had a chance to listen to many of them and I’m just so impressed.

Helen Osborne: Thank you. I learned a lot from Karen Schriver and I hope you did too. But health literacy isn’t always easy. For help clearly communicating your health message, please visit my Health Literacy Consulting Website at www.healthliteracy.com.

And while you are there, feel free to signup for the free e-newsletter, “What’s New in Health Literacy Consulting.” New Health Literacy Out Loud podcasts come out every few weeks. You can subscribe for free to hear them all. You can also find more information about each episode, such as the links that Karen Schriver mentioned, at the Health Literacy Out Loud Website www.healthliteracyoutloud.com.

Did you like this podcast? Did you learn something new? I sure did. If so, tell your colleagues, tell your friends together. Let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.

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