Helen: 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 could help improve a health understanding.

Today I’m talking with Stacy Robison who is co-founder of CommunicateHealth, a consulting company based in Northampton, Massachusetts. As a certified health educator, Stacy uses plain language to meet the learning needs of audiences with limited health literacy skills.

For the past three years, Stacy has been writing and designing health content for the Quick Guide to Healthy Living, which is part of the award winning www.Healthfinder.gov website from the US Office of Disease Prevention and Health Promotion. This site has been tested and developed with close to 800 web users, most of whom have limited health literacy skills.

Welcome, Stacy.

Stacy: Thanks so much for having me.

Helen: Right from the top, I have this question. There are websites for people with limited literacy or health literacy skills. Is that really the population that’s looking for health information online?

Stacy: That’s a great question, Helen. That comes up a lot. I call this a catch-22. It’s one of those situations where you hear a lot of people make the argument that people with limited literacy skills or limited experience on the web aren’t going online for health information. Therefore, there’s no point in even tailoring your web content for this audience.

Helen: I’ve heard that for a while. Can you explain that because we have an international audience? When you say catch-22, are you talking about that book from long ago?

Stacy: I am sort of talking about that book, but what I mean is that it’s a self-fulfilling prophecy. It’s this puzzle that we can’t get out of because we say there is no point in creating this web content for people with limited literacy skills.

At the same time, if we don’t have any easy to understand or easy to use health information online, then folks with limited literacy skills aren’t going to start using the internet to search for health information.

Helen: It’s really this puzzle there. Are people using it? Where are they going? How are they finding it? What are doing about that?

Stacy: One of the issues is that adults with limited literacy skills usually have very little training and experience searching the web. They struggle with reading the content on the page, but they also struggle with managing all the information as they move through a website. There are a lot of different pieces there that affect how these users are interacting with the information online.

This is one of the things that I’ve really enjoyed about working on this Healthfinder project for the Office of Disease Prevention and Health promotion at HHS. They were committed right from the start to building a health information website that’s easy to use and understand, especially for people with limited health literacy skills.

Helen: Are you talking about limited health literacy skills or limited literacy skills? Are you talking about one distinct population, or is there a difference there?

Stacy: They’re related, but they mean something a little bit different. One thing that we did as we were building this Quick Guide to Healthy Living as a part of this Healthfinder website is we used a series of criteria when we recruited the people we wanted to test with, knowing that we wanted to reach these adults with limited health literacy skills.

Using what we know about the prevalence and the populations with limited health literacy skills, we came up with three general criteria. We were looking for people who had a high school education or below, people whose income was below the poverty threshold, and then we looked for people who had not searched for health information on the internet in the past year.

By using those three questions, it was sort of a proxy measure. We were able to feel pretty confident that we were getting people who had limited literacy skills, but because we’re dealing specifically with health information and searching for health information online, we’re also talking about limited health literacy skills.

Helen: Those criteria are really interesting. I haven’t heard anyone frame it quite that way.

You were very clear about who your audience was when you were testing these materials. When you were thinking of those criteria, is that how you were writing it?

Stacy: Yes, exactly. That was a little bit of a workaround because right now a lot of the assessments and measures that we have for health literacy skills are a little bit more related to a healthcare setting, maybe when you’re at the doctor’s office or things like that. They’re also a little bit cumbersome to administer when we’re trying to recruit a large number participants for some of these usability studies.

We worked around that by coming up with these three criteria, and we’re feeling pretty confident that we got the people that we were targeting.

Helen: Now I have a much better sense of your audience. Thank you for that. Can you talk a little bit about the content that’s on your website?

I spent quite a while on there this morning. I am so impressed by what was there. I was clicking here, clicking there, finding a survey, finding more information, and finding something quick and easy. There is a lot there. Can you introduce us to that website in a quick way? If you share the URL, people can be looking at that too.

Stacy: The website is part of www.Healthfinder.gov. The specific tool that we build for users with limited literacy skills is called the Quick Guide to Healthy Living, and right now we have close to 60 different topics in the Quick Guide.

One of the things that’s unique about it is it has a focus on prevention and wellness. This is something that’s really critical when it comes to online health information. If you think about the last time you searched for health information on the internet, a lot of times it’s to look up a specific symptom or diagnosis.

The other day my finger started going numb when I was typing at work, and the first thing I did was go to Google. I think this is true for most people.

Helen: We go online when we have a problem, but wellness is the opposite of having a problem.

Stacy: Exactly, and that’s one of the tricky parts.

In this case, with health promotion and disease prevention information, the users aren’t, as we say, motivated. You don’t always have the motivation to look for information on how often to get your cholesterol checked or how to prevent bone loss as you grow older. There’s an inherent challenge in presenting health promotion content on the web.

Helen: I think that’s a challenge that people in public health and all kinds of settings face all the time. How do you communicate wellness and prevention messages? That’s before there’s that great sense of urgency or pain.

Stacy: One of the main things is that you really want to involve web users in the health content in a way that motivates them. One way that we did this in the Quick Guide is by really looking at people’s self-efficacy. By self-efficacy, I mean a person’s belief that they can be successful in changing their behavior.

Helen: What would that be for cholesterol?

Stacy: When it comes to self-efficacy for something like cholesterol, it has to be helping people feel like they can actually do something. They can make positive changes. They can lower their cholesterol if it’s high. They can take control.

What we did for all of the health topics in the Quick Guide is we included a start-today box.

Helen: Start today?

Stacy: Yes. It has three easy action steps that people can take. These are really simple things like drinking water with lunch instead of soda or testing your smoke detector in your home. They are things that people can do that day.

By doing that, we help increase people’s self-efficacy because the issue doesn’t become so overwhelming. “I need to lower my cholesterol, lose all this weight and radically change all this in my life.” It becomes these really simple steps that people can do right away.

Helen: They’re steps that really go toward that goal. As I was clicking around, I was looking at back pain. I have to watch that because I’m typing all the time.

It goes from simple things you can be doing to just stretch or have good posture. Then you could be finding much more complicated information there as well.

Stacy: Exactly. This is one of the things we found as we developed the website. As you mentioned, we tested it with close to 800 users. We used a real iterative process, meaning we started with early drafts of the website. We tested them with users. We applied what we learned. We went back to the drawing board, fixed it some more and tested it again.

Through this process, one of the things we learned was that people were really looking for just the basics. They really wanted those essential pieces of information, and they wanted to know strategies and actions they could take. We really focused on that. Then we give people the option to drill down further into the content if they want to.

We focus on that basic information you would need to know in order to take action. That really came from all of our testing with users.

Helen: That’s really interesting, but our listeners are probably not going to be developing a website as big, comprehensive and wonderful as yours. They still might have that wellness prevention message. What strategies and actions can they take? What can people take from what you’ve learned after all this testing?

Stacy: There was a lot we learned about communicating the wellness and prevention messages, and there was a lot that we learned about how to write and design a website so that it’s easier to use for people with limited literacy skills.

Over the years of testing, we observed a lot of characteristics of some of these users with limited literacy skills that affect how they use a website.

Before I go into those, I really want to preface that by saying that these characteristics are things that all web users do. I do these things when I’m online too. I sometimes miss links or maybe I mistakenly click. I might not focus on all of the content.

There are a lot of behaviors that we all do, but I think the degree to which we saw them in some of the users with limited literacy skills was a lot greater.

One of the things that we really observed with this user group was about where they were focusing their attention on the screen, and they were looking almost entirely at the middle of the page. They weren’t looking to the left or the right. They were hardly ever scrolling down. What they were really seeing was right there in the center of the screen.

Helen: Do you mean not scrolling down as in not continuing a few paragraphs later?

Stacy: Yes. Very rarely were these users actually using the scroll function. They would get to a page and they would focus on what was right there in the middle and maybe click on a link or two. If there was a lot of content down further in the screen that you couldn’t see, a lot of users weren’t ever seeing that.

A takeaway from that is to keep your most important messages right there in the middle of the screen. We call that “above the fold,” and the fold just means that bottom line of your screen. You want to keep your most important messages right there in the center so users don’t have to scroll down.

Helen: What else can we take from what you’ve learned?

Stacy: We try to use what we call stand-alone sections of text on the website, and that’s because we found that a lot of users with limited literacy skills had a hard time scanning the whole site. Instead of scanning all the text on a page, they would just skip around or skip over whole chunks of text. They might just land in the middle of the paragraph or somewhere further down the page.

By creating a lot of stand-alone subheadings and small sections of text, it would let them move around on the page and still get a full piece of information.

Helen: Even though you said people don’t particularly look to the left or  right, can you put these other sections to the left or right?

Stacy: You still really want to keep them in the center or the screen. The thing about content on the right side of the screen is that a lot of people mistake it for an advertisement, so they have a tendency to ignore it.

I do this a lot when I’m on a website. I block out a lot of what I see on the right-hand margin because I’m just so used to seeing advertisements over there. A lot of people do that. That’s one reason to keep it in the center of the screen.

Another interesting thing that we learned was about really dense chunks of text on a website. We found that people would skip over those right away.

In some of our testing, we actually found that users would skip over a paragraph when there were more than three lines of text. That’s not sentences. That’s actually lines of text.

Helen: They would skip over more than three lines?

Stacy: Yes. They would just say, “Okay. This looks too overwhelming and too difficult. I’m going to just sort of move on and look for some bullets or links.” That’s why bullets are really important on a website. You should also break your text up into small groups, lists and anything to avoid those dense paragraphs.

Helen: Your definition of dense is different from what other people might be thinking.

Stacy: Yes. I’ll say that this is really hard to achieve. A lot of what we learned is really hard to put into practice on everybody’s website. Obviously you’re going to have to put some content below the fold or on the left or right. Sometimes we do need to have more than three lines of text.

These are just some goals to think about. If you can get away from that whenever possible, I think you’re going to keep people on your website a little bit longer, especially these users with limited literacy skills. They’re going to be able to navigate the content a little bit better.

Helen: Stacy, like you, I do a lot of plain-language writing. I do it for other people and organizations. What I find is that one of the hardest parts for them is to let go of content.

You’ve done a remarkable job when you can talk about lower back pain in two or three lines. How do you work with others to let go of some of that content that they want to say?

Stacy: That’s a huge challenge and one that we face a lot in managing this website because it’s a federal government website. All the information we have on the website has to be cleared by subject matter experts in the Department of Health and Human Services. We all know that sometimes these folks have some struggles, as you said, letting go of the words.

I think that’s where it’s really great, and I would really commend the Office of Disease Prevention and Health Promotion on this. You really have to be an advocate for those limited literacy users and audiences that you’re trying to reach.

When you can keep coming back with that, keep making a case and letting people know that you’re conveying the same information, you’re just doing it in fewer words. I think you really have to be determined and you have to be an advocate.

That comes across overall in the writing style in the Quick Guide. It’s really familiar and simple language. Word choice is an important part of that.

Helen: I get the sense that it’s also respectful. You’re not talking down to me. I might go there to learn about whatever condition I want to be learning about. You’ve done a remarkable job, and I really encourage podcast listeners to go to the site and see how you’ve put these principles in place.

I know you’ve done this website for this specific audience of people with limited literacy or limited health literacy skills. Are you finding that other people are going to the site too, or is that just for that distinct group and other users go elsewhere?

Stacy: No. The site is really popular. You deal with this a lot, Helen, and I know a lot of people do in the health literacy world. There’s that misconception and misperception that by writing content for folks with limited literacy skills and limited health literacy skills, you’re somehow dumbing it down or not making it relevant or interesting to people who may have stronger literacy skills.

That’s just not the case, especially with online health information. It’s different than print information. This is something I think that Ginny Redish has really done well.

Helen: Ginny Redish is one of our podcasts. We’re put a link there. Her book is about letting go of the words. She’s masterful at making websites that work.

Stacy: She is tremendous at it. I think it’s the idea that people go to websites to answer a question or do a task. A lot of times they’re multitasking. Short, simple, succinct content benefits all of us and certainly is the most appropriate way to write for the web.

When we talk about what we did with the Quick Guide to Healthy Living, a lot of times we say it’s for people with limited literacy skills and people with limited time. I think that’s really key because, frankly, that’s most of us.

Helen: That is. Thank you so much for sharing all that.

I have one more question before we go. You talked about how you frame your message in terms of actions people can take today. Looking ahead, what actions would you like those of us communicating health messages to take tomorrow?

Stacy: What I really love about working with health information on the web is working with web designers, and I love people who work in the world of usability. In our world of health literacy, our measures are all about the individual, their skill level and literacy skills, and how well they can understand things.

In the web world, it’s completely different. You design a website. You test it with users, and then you see where users are getting stuck when they’re on your website. Can they find the information? Do they know how to click on the button?

If they don’t find what they’re looking for or they’re not able to do the task, as the web designer and the web writer, you go back to the drawing board and fix it. It’s never a fault of the user. It’s the job of the web writers and designers to make the website clear and easy to use.

I love that. I think that’s sort of a reframing of health literacy and clear communication. I would love to see the field move a little bit more in the direction of taking that burden off of the individual and putting it on us as communicators, writers and designers.

If people don’t understand and they’re not finding the information, then we need to go back to the drawing board and do our jobs better.

Helen: Stacy, thank you. What a wonderful way of wording concepts I so whole-heartedly agree with. It’s not about what other people can’t do. It really is about what we can and will do. Thank you so much for sharing your experiences and lessons learned with all of us.

Stacy: Thank you for having me. This was really fun.

Helen: I learned a lot from Stacy Robison and hope you did too. Health literacy isn’t always easy, and we talked about that.

For help clearly communicating your health message, please visit my Health Literacy Consulting website at www.HealthLiteracy.com. While you are there, feel free to sign up for the free monthly e-newsletter, “What’s New in Health Literacy Consulting.”

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can go to the website and learn more information about each episode along with important links at www.HealthLiteracyOutLoud.com.

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