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 this podcast series, 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.

Today I’m talking with Dr. Donald Rubin, who is Emeritus Professor of Speech Communication, Language and Literacy Education, and Linguistics at the University of Georgia. He is also senior researcher at that institution’s Center for Health and Risk Communication.

Much of Don’s work focuses on assessment, training and analysis of oral communication, including something he refers to as “listenability.” His current project looks at health literacy and health communication message design. Don’s talents go beyond these many academic accomplishments. When he’s not designing communication messages, Don’s in the kitchen cooking up soups, stews and stir-fries. Welcome, Don.

Don: Thanks very much, Helen. I’m glad to be online with you and your audience.

Helen: We’re all in this one together, and we all want to hear about oral communication. Boy, wouldn’t my husband want me to learn a lot about listenability? It sounds like quite a talent.

Let’s take it from the top. Your interests are communication, which is evident by all your accomplishments, but also cooking. Is there any connection between the two? How are these two concepts alike?

Don: My concept of cooking is not necessarily by the cookbook. I always feel that the best way to cook is improvisationally. I get some kind of idea of what I would like the end product to look like, but the truth is when I am in the process of cooking I see a spice or ingredient that appeals to me and I pull that in. That might affect my next choice.

Really, that’s the way conversations work, too. Conversations may have some sort of an endpoint in mind, but we improvise our way to them. By the time we get to the end of that conversation, it often ends up in a very different place than we may have anticipated to begin with. That’s sort of the stew theory of conversation.

Helen: I like this metaphor. I could keep going with how they’re alike. It makes it very real to me when it’s something as abstract as how we talk and listen.

I know in health literacy there’s been a tremendous amount of focus on the printed word. You need to write it just so, measure it just so, and all those rules. How do those rules apply? What’s the difference with how we talk and how we listen?

Don:I want to begin by saying I have a tremendous amount of respect and appreciation for all of the work that’s gone into improving the readability and, even more important, the usability of all of the health documents that patients and consumers need to process in order to navigate the health system and protect their own health. I’ve participated in that work as well.

Sometimes it feels to me as if we have a little bit of a blinder on in our field of health literacy. We forget just how people process a lot of the printed information they receive. They actually process it in conversation.

Helen: Let’s make this real. We’re all just listening to this podcast. Help make this more clear. How do people process written information and spoken information?

Don: One of the most tangible ways to think about it is to think about how quickly we can read and how quickly we can listen, and how much effort it takes to read and how much effort it takes to listen. The scientists have told us for several decades that we read a lot faster than we listen.

Most people can read about 300 words per minute. If you’re like John F. Kennedy and have taken a speed reading course, you can perhaps read 1,000 words a minute or more. Most people can only speak at 125 or 150 words per minute.

Helen: That’s a big difference.

Don: That is a big difference. That means when we are listening, we are actually receiving information a lot slower than we are capable of processing it. We are capable of processing at least 300 words a minute, but when we listen we only receive 150 words per minute.

Helen: When you say “listen” do you mean really listen, or just that those words fly by and not much sinks in?

Don: I’m glad you brought that up, Helen. There is hearing, and then there is listening. When I say listening, I mean processing, understanding and going beyond the words given to try to figure out what the implications are for me. That’s where I was going when I was saying we have a lot of spare time when we’re listening because we are capable of pulling in a lot more information than we’re receiving.

What do we do with that spare time as listeners? If we use it well, we have the opportunity to make the connections, links and personal implications with the information.

To make that more concrete in terms of health information, when we are listening to somebody deliver a message to us, we have the leisure to say, “How does this apply to me? How am I going to use it? How is it going to affect my health?”

Helen: Does that mean we’re listening to what the other person is saying, but we’re kind of listening to what we’re saying inside? We almost have two conversations going on at once?

Don: We could call it two conversations I suppose, but I like to call it deep listening. Deep listening is more than just receiving the words. Deep listening is also taking those words and incorporating them, making them yours.

Helen: Can you give an example?

Don: One of the best examples I like when I talk about the idea of interactive health literacy, the term we have been using for this conversation, has to do with how people make the decision to get an H1N1 vaccination.

Helen: H1N1 is the flu we’ve been dealing with lately.

Don: That’s right. It’s been much in the news. Information out of the CDC is that given the huge amounts of publicity that H1N1 has received and the tremendous amount of material on the web and newspapers, in the end, fewer than 40% of eligible Americans actually took an H1N1 inoculation.

The question is how people made the decision to receive it or not. We all watch the evening news or “Good Morning America.” We heard all these wonderful spokespersons talking about it. Some people hear the message about the importance of H1N1 and hear it as just another government warning. They don’t necessarily apply it to their own health.

Other people listened really carefully to that message. They deeply listened to it and said, “What are the risks to my family,” for example, “if I should get H1N1? Do I really want to subject my family to those risks? What would happen in my workplace if someone got H1N1 there and I was not protected against it?”

The people who listened to that message deeply were the ones who made the connections to their own life circumstances. The people who just listened to it might have the same information, but didn’t tie it to their own circumstance. They never saw it as a decision they needed to make for themselves.

Helen: Don, if I talk about something I’ve learned, and I do this in all of my writing, always in the first paragraph and usually in the first sentence, I use the word “you” because I want the person to know it is for him or her. I’ve heard of this principle by the acronym WIIFM, “What’s in it for me?”

When I start giving messages, I always start that way. Even in these podcasts, I like to introduce that way. What’s in it for the listener to get from this? Is that a principle that you’re talking about with this deep listening?

Don: It certainly turns our receivers on when we get that what’s in it for me message right from the beginning. I sometimes use that same acronym. I say it’s one radio station that everybody likes to listen to, WIIFM.

If you can let people know, “Here’s a message which is not just coming at you for academic reasons or because the government is trying to promote yet another program. Here is information you can use that will help you in your own personal circumstances,” of course people are going to engage in that deeper listening process, going beyond the words uttered and trying to make the connections with their own situation and personal health.

Helen: Is that a strategy for those of us communicating health information to help the receiver of this message make that application in their own life?

Don: Absolutely. I like the idea of starting every opening paragraph with the word “you.” One of the ways in which written and oral language is distinguished is that oral language has a lot more of those personal pronouns.

When we speak face-to-face, we obviously use “I” and “you.” Those are the two parties in the conversation. Sometimes in writing we try to depersonalize things and use the third person more often.

Helen: With “the patient,” “the person”?

Don:“The patient,” “the person,” or “the client who is coming for counseling.” It’s that sort of thing. If we could remember that people get engaged by interpersonal interactions, we could try to make our writing a little more interpersonal. One of the ways of doing that is to use personal pronouns.

We all got our wrists slapped when we tried to use the word I in our high school essays, didn’t we? I think if we used “I” and “you” a lot more in our writing, that would simulate oral language and help people see that there is going to be something in this message for me.

Helen: You’re the expert on oral communication. I realize a lot of my questions are about the written. Let’s get into the oral. How can we, as communicators, create an environment where people really can do this deep listening and deep understanding?

Don: First of all, when we speak about environment, we can speak about physical environment.

We’ve been doing a lot of workshops lately about communication between pharmacists and customers who come into drugstores. We believe pharmacists have a tremendous amount of health information. If we could encourage more citizens to take advantage of the huge knowledgebase that exists on the corner of every Main Street in the United States, that would be a tremendous way to get across a lot of health information.

One of the problems with communicating with your pharmacist is that you’re standing in the middle of a retail environment. Very often, there is some embarrassment or desire for privacy which seems to be violated when I’m standing in between the toothpaste and deodorant.

Some pharmacists have managed to arrange a little space for consultations, even if it’s just with a bit of a barrier, a cubicle kind of arrangement where the pharmacist can go tete-a-tete with the customer. There’s no visual distraction, and you get a feeling that someone would have to be working really hard to listen in to this conversation.

That kind of environment really improves the capacity for a real health communication interaction between a pharmacist and a client. The same thing is true in the physician’s office as well. I know you have spoken and written about communicating naked.

Helen: For listeners who may not know, the article was “Communicating When Naked: My Perspective as a Patient.” What I was getting at was that feeling of vulnerability and fear, or all the ways that stand in between communication when you are scared, sick, and indeed naked, talking with someone who is all dressed up, standing up, with a voice of authority. It’s a real inequity, and it can really interfere with communication for at least a while.

Is that what you were talking about?

Don: Absolutely. What’s our number-one concern in the examination room? Trying to keep that strange little string tied in the back of our gown. It’s very hard to be even a little assertive with your physician. You might want to get a little more information out of the physician, or perhaps get the physician to think a little outside the box he or she is thinking in. It’s hard to assert yourself when you’re worrying about that string getting untied in the back of your gown.

All of that relates to the physical environment of communication that might present barriers to listening. There is also a linguistic environment which promotes listening. The linguistic environment is one, frankly, which might require a little more time, being a little less rushed so that if I have a story to tell, I can get that story out.

In the typical managed care environment that many healthcare interactions occur in, sometimes time is at a tremendous premium. That clearly is a barrier to good listening.

Helen: What can we do about it? I don’t think that time issue is going to get any better soon.

Don: There is some data I’ve looked that suggests the average consultation with a physician in the examining room is about seven minutes long. When that time can be stretched to nine minutes, there is an appreciable increase in patient satisfaction. We’re not talking about 30-minute interviews with our doctors or limiting the doctor’s capacity to see patients by any quantum amount.

A lot of times, if doctors could set aside two minutes extra for a patient and say, “This is your time to talk and my time to listen,” just those two minutes could make a huge difference in terms of patient satisfaction.

We know that patient satisfaction is also related to patient compliance. If we’re concerned about medication compliance, for example, people actually taking their meds the way they’re supposed to take their meds, two minutes extra in the consultation room might make a big difference.

Helen: You raise another point that intrigues me. You talk about listenability, but you’re also talking about silence. We don’t always need to keep chattering away, do we?

Don: Silence, for a physician or other healthcare providers trying to elicit information from a patient or customer, is one of the most powerful tools. There is a saying that nature abhors a vacuum. A conversation abhors silence.

We all have a natural inclination to want to fill that space when we’re face-to-face with somebody. We find it very uncomfortable. In fact, a pause over two seconds long is a pretty noticeable pause. If we stretch that pause out to 10 seconds…

…that’s pretty uncomfortable.

Helen: Boy, did I want to interrupt you and say something!

Don: You showed great self-control there, Helen.

Helen: It is. I hope our listeners stayed with us through that pause. It’s even hard to listen to. Was that 10 seconds?

Don: That was 10 seconds, yes. If a physician or any kind of healthcare provider is interested in eliciting information from a patient or customer, imposing those kinds of silent pauses is a very powerful tool. It’s probably even more powerful than asking direct questions. A lot of times, patients are not very well prepared to answer questions. They may answer them in very vague ways. When they’re confronted with silence, they will open up and do whatever they need to fill that silence.

Helen: I find that fascinating. Right there, you talked about time and adding a couple more minutes. It seems maybe we can get there. Maybe we can add two minutes. We can’t change the whole healthcare system, but maybe we can just be quiet for a moment or two. If that can go a long way in improving understanding, it’s really accomplishing a lot.

Don: It really can go a long way just to give people space in the conversation for them to fill and not always feel that the person who is in the position of power, namely the healthcare provider, is the one who needs to do all the talking. If we went back to our original metaphor of conversation as a stew we’re making, it invites you to decide if you want to add a little more salt or maybe a little more pepper.

Helen: I like going back to that. I know that some of your research now is focusing on older adults and communication. Could you tell us a little about that, please?

Don: We know from all of the research and testing that has been done using measures of written health literacy, the wonderful tools we have for written health literacy, that older adults often come out looking worse in terms of health literacy skills. They seem to come out very poorly in terms of the capacity to acquire and understand information.

The irony is that when we ask older adults, “How satisfied are you with your healthcare?” typically older adults say, “I’m really satisfied with my healthcare. My doctor is so smart and cares so much about me. I know that my doctor takes really good care of me. I’ll do anything my doctor tells me to do.”

When they walk out of the appointment and you ask, “What did you learn in your doctor’s office?” they say, “I really don’t know, but my doctor is smart and really cares about me. I’m satisfied with my care,” but typically come out knowing very little. One of the reasons is because their level of participation in that health encounter is so low.

Older adults have low health literacy, although they have high satisfaction.

One of the things we’re trying is a project we call Health Literacy on Wheels.

Helen: Health Literacy on Wheels. Isn’t that interesting?

Don: It’s Health Literacy on Wheels because we’re delivering our training via community members who have tremendous trust and access to older adults, Meals on Wheels volunteers.

Helen: I see the connection.

Don: Meals on Wheels volunteers are welcomed visitors in the homes of many older adults every day, bringing nutrition. In the course of that interaction, they know their clients really well. They know their clients’ health status well. They’re trusted and welcomed. We feel if they can bring a little training in health literacy along with them, that’s a very teachable situation.

The instruction in health literacy that our Meals on Wheels volunteers bring with them is how to ask questions when you’re in the doctor’s, or any health provider’s, office, how to be a little more participative so not only will they feel satisfied, which they already do, but they will also be able to say, “I did learn something. I had a question I needed the answer to, and I had my question answered.”

Helen: That’s a very interesting way of paring that together. I sense a theme here. You’re still bringing together food and communication.

Don: That’s true. We say the way to a man or woman’s heart is through food. That’s also the way to health literacy.

Helen: What a nice way to do it. Before we leave, if we could add a special spice or ingredient to our communication spice shelf, what would you like us to add?

Don: I am an advocate for eating fresh foods, so I think it’s important for any healthcare provider to be able to look at each patient or client who walks through the door as a new person, as an individual.

It’s very easy when you see 12 or 20 cases a day to not be able to engage in that active listening process and go through the health interview and counseling as if it were a recipe and each dish gets prepared the same way.

I think it’s important that those healthcare providers who themselves exhibit the greatest health literacy, and who encourage the most health literacy among their clients, don’t go through their interviews as if it were a recipe. Instead, they should look at the fresh ingredients in front of them. What makes this person unique, and what is this person bringing to the interaction? Talk to that person one-on-one like an individual human being.

That ability to take the ingredients as they come to you is the way I would say we prepare a successful dish of health information.

Helen:Thank you. I, for one, think I will be thinking about you the next time I’m in the kitchen. I will be thinking about you, health literacy, and how I put all the different pieces together.

Thank you so much for sharing that with the listeners of Health Literacy Out Loud.

Don: It’s my pleasure.

Helen:As we just heard, there’s a lot to health literacy. It’s not always easy to put all the different pieces together in just the right way to make sure the message is listenable, understandable and actionable.

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

New Health Literacy Out Loud comes out every few weeks. If you subscribe, you’ll hear them all. You can learn more about each podcast along with references we mention and links by going towww.HealthLiteracyOutLoud.com.

Did you like this podcast? Did you learn something new? If so, tell your colleagues and 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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