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 truly remarkable 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. Annetta Cheek, who is an ongoing champion of plain language. With a background in anthropology and many years of experience as a federal employee, Dr. Cheek helped lead the way to convincing the US Congress to pass the Plain Writing act of 2010. Now she and others are supporting new legislation to streamline government regulations.

Dr. Cheek’s commitment to plain language is longstanding. Among her many accomplishments, she served as an expert for Vice President Gore’s plain language initiative. More recently, she helped found the nonprofit organization the Center for Plain Language. Welcome, Annetta.

Annetta: Thank you. I’m really glad to be here.

Helen: You’re tackling writing [government] documents in ways that all of us can truly understand. You’re not shy about taking on challenges, are you?

Annetta: No. I expect that I’ll have plenty to do for the rest of my life and probably another couple of lives should I have them.

Helen: I’m cheering you on because I certainly can’t understand some of the gobbledygook I need as a small business owner.

Let’s start from the top. What do you mean by plain language? Then we’ll get into this legislation.

Annetta: There are really two parts to defining plain language. The most important part is the underlying principles that say your material is in plain language if the people that you are trying to talk to can understand it the first time the read it and find what they need in your material and use it to satisfy their needs. The bottom line is that it’s useful. The test of whether something is plain language or not is whether your intended audience can use the material.

Of course, there are also a lot of techniques that help you get there. Sometimes people confuse them with the definition of plain language, and while we say those are all very useful and maybe even necessary to get you to that goal of useful communication, they are not part of the definition of plain language. Those are things like using active voice, using pronouns and lists, keeping your sentences reasonably short and so on.

Helen: I thank you for distinguishing between those two because I often serve as a plain language editor and writer, and people come to me wanting some help. That seems to all get muddied together, and then you throw in some standards about readability. We’ve got a hodgepodge there. Thank you for adding that clarity to what plain language is all about.

Let’s take this further. You have been very active, and thanks to you and others we have some national laws, regulations and upcoming work ahead of us. Please tell us about the Plain Writing Act of 2010.

Annetta: We at the Center for Plain Language went up to Congress starting back in about 2007 to try to educate them about how important clarity of communication from the government in particular was. I do have to give credit to Mr. Braley, the congressman from Iowa who introduced the bill and is very dedicated to this personally.

He comes from a background as a trial attorney and saw much confusing language in his career. He believes that unclear communication from the government is a burden on the citizen, and so do we.

We think that citizens have a right to clear communication from the government, and that’s what the Plain Writing Act of 2010 is all about. It took us several tries to get it through, but obviously we eventually got it and had a big celebration.

Helen: Yay! You go! What does this mean for the rest of us? Now that this has been enacted, you understand the nuances. I saw press releases, and I thought, “Yippee, Plain Writing Act of 2010.” My second thought was, “What does that mean for me?”

Annetta: Hopefully, what it means is when you get a letter from Social Security or have to deal with an IRS form or any other kind of communication from the government, it will be easy to read.

We don’t delude ourselves into thinking that this will happen overnight. Frankly, some agencies are more committed to implementing this than others.

I think I’ve already seen an increase in awareness of the issue, and we do see some agencies that had never been involved before starting to talk about training and so on. I think we will see a gradual improvement overall. Of course, there will always be the dark holes where we don’t see any improvement.

Helen: Do they have to do this?

Annetta: They must do this.

Helen: Why would we have dark holes from people not doing it?

Annetta: I was a fed for 25 years. There are a lot of things that federal agencies must do, and resources are decreasing. It can be on your list and in your plans, and you just don’t have the resources to do it. Depending on how important you think it is, you may just not find the wherewithal to get it done. There is no real enforcement mechanism. Nobody is going to come and take the head of the agency away to jail if he doesn’t do it. There are “musts,” and then there are “musts.”

Helen: Thank you for putting a voice of reality on that one.

I just saw a press release that there is new legislation that you are working with Congressman Braley about. Tell us about that.

Annetta: This one addresses regulations specifically. The reason Mr. Braley did that is because in the first round of the Plain Writing Act, we lost regulations to various political pressures.

Helen: By regulations, can you just give us an example?

Annetta: It’s something that a lot of the public doesn’t normally read, but some segments do. It’s what really tells you what you have to do in certain circumstances. It’s called “The Code of Federal Regulations.”

For example, there is one that I personally had to deal with some time ago because I was hosting a foreign student. We were trying to figure out when he could get a paying job. I had to go to the federal regulations and read very detailed legal language about when a foreign student could work, where he could work and so on.

With everything that the government tells you to do, behind them   there is a regulation. Basically, Congress passes a law and the executive agencies write regulations to implement the law.

Helen: Thank you. I know that as a small business owner, I am faced with some federal regulations too. There is one document that I get yearly, and when I look at it I just cringe. There is no way. I don’t have a team of lawyers helping me out so I just click “yes.” I don’t even know what else to do.

Annetta: Exactly. That’s the major reason Congressman Braley introduced the new act to get relief to small business owner. The regs are a huge burden on business owners, and many of them aren’t really all that burdensome if you could just understand them.

Helen: Thank you and Congressman Braley for continuing to champion that cause.

We have a variety of listeners on this podcast. They are people working as clinicians in public health, teachers, librarians and quite a variety of people. Why does this matter to them? Maybe they’re not a small business owner like me or a federal employee like you were. Why do the Plain Writing Act and the upcoming one affect us, and why should we care?

Annetta: Everybody is affected by a federal regulation one way or another, even if you’re not aware of it. All of those IRS forms that you get and file are based on regulations.

Even though you may never read the regulation itself, when the agencies are implementing a reg and writing some instructions in a form that you have to fill out to report on your research, they are responding to the requirements in the reg. When they don’t understand the reg, what they tend to do is just repeat the reg language because they don’t know what else to do. That bad regulatory language flows down from the regulations that people rarely read into the material that everybody gets.

Helen: I’m thinking about HIPAA, the privacy protection act. Is that an example? Over and over again I hear from organizations that we need to use this mandated HIPAA language, and it’s a bear for people to understand.

Annetta: Exactly.

Helen: Are you saying that once this new legislation gets enacted, people won’t be so locked in, or is it already that we’re not so locked in but people just think we are?

Annetta: Often you aren’t really locked in. People just find it safer to repeat the regulatory language. I don’t know about the HIPAA situation either. It could be that they say, “You must say this,” or it could be that it just says, “You must communicate these principles.” Then it leaves it to the writer to express it, but because the writer doesn’t understand what the reg says, he just uses the reg language. That certainly happens often.

There used to be a very difficult and actually funny regulation about exit row seats on airplanes. You may remember them. You would be at the exit row and get your little plastic card. It would have this information that included things like, “You must have the aural capacity to understand the stewardess.”

Excuse me. All they meant was, “You must be able to hear,” but you can’t write a regulation that way. You have to things like “aural capacity.” The airline wasn’t required to use that language. They were just required to convey the same idea. They could have said, “Can you hear the stewardess?” Because it was so complex, it was just easier to take the reg language and pass it on down to the customer.

This is a safety issue. You’re telling people these very complex instructions in overly complex language, and it could be a safety issue if there were a plane crash. People don’t think about the consequences of that bad communication.

The regulations have been cleaned up a bit, and people poke so much fun at this that more airlines went to the trouble of rewriting it into something that people could understand. There for a while, the airlines were just using all the bad regulatory language.

Helen: That’s a great example of how things just start so hard. There’s really no reason to keep using that language. You talked about it as an issue of safety. My focus and our listener’s focus and passion is often about health communication. Certainly, when we communicate in complicated ways, it is a matter of safety. It can be a matter of life and death.

Annetta: Absolutely. I really don’t know how the government got into this culture of complex communications, but it has certainly been building. We don’t expect a revolution overnight, but we’d like to change the direction away from this complex language back toward something that everyday people can understand.

Helen: You just used a term that I really like. It’s the culture of complex communications. I see that in many industries including in health. Our listeners are people of influence whether they are communicating with one person at a time each day or whether they communicate in print, on the web, in groups or on podcasts. There are a lot of ways of communicating. What would you like for them to know and do about plain language?

Annetta: There is a two-part answer. First, as far as the federal language is concerned, part of the Plain Writing Act is a requirement that agencies have a web page where people can write to complain about unclear language, praise an agency’s efforts or ask questions. I would encourage everyone to use that new access point to impress upon agencies the importance of writing clearly.

Helen: You said that every agency has a website. Is there a specific place or do you just go to “Contact Us?”

Annetta: The act says there is a page or link from the home page to issue this kind of comment. A large handful of agencies have their websites up. Others do not. The deadline has passed, and they should all have them. If you go to an agency’s website and it’s not obvious where to go for this, then I would use “Contact Us” and say, “Where is your plain language webpage?”

Helen: We could be advocates for this.

Annetta: That’s right. The other half of the answer is that if we’re talking about your listeners as writers, I think there are three points that are most important. I do train plain language a lot and you can get into a lot of detail about techniques. One of the most important things is to use active voice. Use none of this, “Research was done. Results were analyzed. Reports were issued.”

Helen: Those are all passive.

Annetta: Get rid of all that passive and make it clear who is doing what to whom or to what.

Helen: It should be, “Our agency issued a report,” rather than “Reports were issued.”

Annetta: That’s right. The second one is to keep your sentences reasonably short. We get these huge, long sentences. My husband just read me something from the newspaper about a judge who rejected an attorney’s filing because it had a 345-word sentence in it. He’s threatening to not allow him to practice before that court anymore because he’s so tired of the battles on writing.

Helen: When I teach about this, I encourage people to not use all of that punctuation that we learned in high school, college and graduate school. Just use your noun and verb and make your point.

Annetta: Exactly, and then get out of there. There is an infinite supply of periods in the universe. You will never ever run out, so feel free to use more.

Helen: On the other side of that, I’ve sometimes seen where people are so fixated on needing a short sentence, and it comes out so choppy.

Annetta: We know that’s a danger, and we say that for normal writing an average sentence length of 20 words is about right. That means that some of them will be shorter and some of them will be longer. If they’re all in the 18- to 22-word range, it comes out very choppy.

Helen: Thank you. Then there’s some wiggle room and judgment in there.

Annetta: We would say it’s an average of 20 with no single sentence longer than 40.

Helen: Thank you for that. In my writing, I also sometimes write some very short sentences. It seems to be a little bit more artful. Sometimes I also start sentences with “and” or “but.”

Annetta: That’s perfectly fine.

Helen: It’s time to throw out some of those old rules.

Annetta: Who came up with them, anyway?

Helen: My English teacher did. What is your third point?

Annetta: This developed in my mind later as I read more and more. Leave out material your reader doesn’t need. That will really shorten what you write. Just think about everything you’re putting in there. Does the reader really need this to get the job done and to get to that goal of information that they can use to satisfy their needs?

We all seem to have this tendency to want to tell people about our program. I’ve seen several web pages that say, “Since 1976, our office has taken pride in providing the public with the best service about ____.” No one cares. They just want to know what they need to do today.

Just cut out all of that extra stuff that you would like them to know because, frankly, they aren’t going to read it. The more padding there is, the less likely they are to read the important stuff.

Helen: A term that I use is one that I didn’t make up. Others use it a lot. It’s to differentiate between need-to-know information and nice-to-know information.

I also often tell people that the hardest part about plain language is letting go. When you have a document that you’re working on that was written by content experts such as scientists, administrators and risk managers, there’s a lot in there that is buried under all of those syllables. Some of the resistance that I get is, “We want this, that and the other one.” It seems to be hard for content experts to let go of some of the content.

Annetta: Exactly, and you’ve come back to the issue of culture. There is an important principle about plain language culture. That is that the reader is first, not the writer. I think the basic problem with most bureaucratic writers in government and business alike is that it’s about the writer, the writer’s boss, the writer’s attorney and the writer’s friend down the hall. It’s not about the reader.

In plain language the reader has to come first. You have to think about them, what they need and what they don’t need.

Helen: Thank you. It’s all about us.

Annetta: It is all about you, absolutely. It’s not about me.

Helen: I love that. How can people learn more about all of this?

Annetta: There are many sources. The center that I am the chair of, the Center for Plain Language has a website. It is www.CenterforPlainLanguage.org.

There is also a federal website. It is a federal group that was founded back in the mid-90s that is a voluntary group. It’s not official, although it is a government website. That is www.PlainLanguage.gov.

If you are writing for the web, there is a great book that sprang to mind because you used the words. The name of the book is Letting Go of the Words, by Ginny Redish.

Helen: We actually did a podcast with her.

For all these resources and the legislations out there, we will have those links on the Health Literacy Out Loud website for this podcast.

Annetta: That’s great. The Plain Writing Act is linked from both the Center site and the www.PlainLanguage.gov site. I know that on the Center site, we have the text of the new bill up on the site.

Helen: This is terrific. You’re obviously a champion. You’re a champion for all of us as readers, as users of material and as writers. I thank you so much for sharing this information with listeners of Health Literacy Out Loud.

I learned so much from Annetta Cheek and hope that you did too. Health literacy and plain language isn’t always easy. 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 find us on iTunes, on the mobile app Stitcher Radio and on the Health Literacy Out Loud website, www.HealthLiteracyOutLoud.com.

Did you like this podcast? Did you learn something new? 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.